HomeMy WebLinkAbout750 Shipyard LnTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/12/03
Transaction(s):
Permits
ReceiptS:
2450
Subtotal
$45.00
Check#: 2450
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 83930
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#T100342627
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. - HICKSVILI.I~ NY 11801
Name of Applicant Address
2) 750 Shinvard Lane, East Marion
Name of Owner of Premises
Address
3) Shiovard lane - bellhole e/s paved area approx. 222' s/o Marina Lane~ East Marion, for a gas service to
0750
Work Description and Location (Street Number, Hamlet, Cross SWeet)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*lf yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
s)
Electrician's License No. Other Trades License No.
Date
a) Attach plot plan showing location of propased excavation and relationship to adjoining premises nc
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach aH 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
7) Starting Date: Completion Date:
8) Work Schedule:
, Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39 Page 1 of 3
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:
13) Security:
a)
b)
T100342627
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and pernuts: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service ~ $10.00 = $
No.
$25.00
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:
0-100 l.f. = $30.00 =
~ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.fi ~ $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
/
Received by the Town Clerk
q/2~/0 Date
Permit Issued ] .~ Permit No.
Authorization is hereby gyanted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance w/th this application.
SUP/ER~NT OF HIGHWAYS
Not~e: Permit expires one ( 1 ) year from Date of issuance. No work to start w/thout 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
L%24' O~MON) 08:15
BU~S DESIGN PATGH TEL:S16 75851~6
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