HomeMy WebLinkAbout1025 Hill Crest DrTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/12/03
Transaction(s):
1 Permits
Receipt#:
2476
Subtotal
$45.00
Check#: 2476
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 83929
Permit No. ~ ~ ( ~
File No. C~_fvj ]
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
Re£#T100344928
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) 1025 Hill Crest Dr., Orient
Name of Owner of Premises
Addr~s
3)
Hill Crest Dr. - bellhole s/s of Hiill Crest Drive, 230' e/o Soundview Drive, Orient~ for a gas service to #1025
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.
Electrician's License No.
S)
Plumber's License No.
°ther 7_
Date
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 necessa~ permits and licenses for this project.
c) Work covered by this application maynotcommencebeforeissuanceofaHighwayExcavationPermit
by the Town Clerk.
6) Tax Map: Section ., Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
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
T100344928
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
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and oermits: 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.£ = $10.00
1.£ ~ $0. i0 = $
Additional
Excavations 18" in depth to 5' in depth:
0-1001.£ = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 1.£ = $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.
SUP/F~I'~ENT OF HIGH~/AYS
TpW OF S g T D, NyOr¥O
/ Date/
Received by the Town Clerk
Permit lssued / / ~' Permit No. 0~ ~t~
D-39 Page 2 of 3
~ PER1VIIT APPLICATION SKETCH
DATE:
LOCATI ON:
TOWN:
WORK ORDER:
12/2/20031:2P:~ PM
102_5 HILL CREST DR.
ORIENT
Ti O03Z14~2g
VILLAGE
srP. EET: SOUNDVIEW RD
NJP. FACE:
Macad~a Road
H~se NO.
Bell Hole
Z
0
HILL CREST DR