HomeMy WebLinkAbout1455 Albo DrTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/12/03
Transaction(s):
Permits
ReceiptS:
2316
Subtotal
$75.00
Check#: 2316
Total Paid:
$75.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 83934
Permit No. _~
File No. ~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
PERMIT FOR EMERGENCY GAS LEAK REPAIR
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100336746
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for the excavation herein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1455 Albo Drive. Laurel
Name of Owner of Premises Address
3) AIo Drive - bellhole e/s paved area and a 100' trench in the ~rass area annrox. 350' n/e of Wells Road.
Laurel. to install a Mas main and service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __X __
*If yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
Electrician's License No. Oth~'~ade's Li~ No.
nature/~f A~pli~:ant
Date
5) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section ~ Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase Completion Date
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39 Page 1 of 3
T100336746
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of ceffification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee ................. $25.00
Al. 1 /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service ~ $10.00 - $
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
l.f. @ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f.: $30.00 = ~ k.~ ~ , ~"'~
__ 1.f. @ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.f. ~ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service @ $5.00 = $
Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST ~ 7 ~'~'ft~
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUP~-~NT OF HIGHWAYS
Peter W.
Received ~¥ the
Pe~t Is,u~ / ~//~/a
Note: P~t expires one (1) ye~ from Date of Issuance. No work to s~ ~hout 48 hour notice to the Sup~m~d~t of Highway.
P~it must be available ~or
D-39 Page 2 of 3
O~T,-31' O~(FRIIi 10~27
P. 002
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