HomeMy WebLinkAbout1280 Lands End RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/12/03
Transaction(s):
1 Permits
Receipt#:
232O
Subtotal
$45.00
Check#: 2320
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 83933
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
ReL#T100337084
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 deacribed. 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
2) 1280 Lauds End Road, Orient
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
s)
6) Tax Map: Section
7) Starting Dat~:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & CompacOon .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Address
Address
Lands End Road - 4'X4' bellhole wis grass area approx. 585' s/o Latham Lane~ Orient, to install a cas
service to house//1280
Work Description and Location (Street Number, Hamlet, Cross Street)
(a} Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
Plumber's License No.
Other Tra~ License No.
a) Attachplot plaoshowinlloc~tiouofproposedexcavatiouaudreintioushiptoadjoinlugpeemisesor
public streets or areas, aud liviu8 a detailed description of in¥oot of excavotion.
b) Attach ~11 other uecessary permits aud Iiceuses for this project.
c) W~rkc~veredbythisappHcati~nmayu~tc~mmencebef~reissuauce~fuHighwayExcavati~nPerm~t
by the Town Clerk.
, Block , Lot
Completiou Date:
Completion Date
D-39 Page 1 of 3
T100337084
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification 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. ! /Service Connections excavations ~ $20.00 = $ 20.00
No.
3,2. /Additional Excavations same service ~ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 1.£ = $10.00
_l.f. ~ $0.10-- $
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. -- $30.00 =
__ 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 $45.00
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.
SUPf~'~'I~DENT OF HIGH)VAYS
- yet?WS , -
Received by the Town Clerk t/°2~ ~'~'/~9 ~
Permit Issued Permit No.
t~[q!~: permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
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