HomeMy WebLinkAbout1640 W Gillette RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/04/03
Transaction(s):
Permits
Receipt~:
2417
Subtotal
$345.00
Check#: 2417
Total Paid: $345.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC rntemal ID: 83711
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100340651
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) W. Gillette Road, East Manion
Name of Owner of Premises
Addr~s
3) W. Gillette Road - bellhole e/s paved area and a 1000' trench in the e/s grass area~ approx. 546' s/o
Manor Place, with a missile shot across Midland Place, East Marion, to install a gas main and gas
service to #1640 W. Gillette Road.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls 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.
s)
Electrician's License No.
Other Trade]s License No.
'~' //Signature ~rAppli~j~n~0
-- 11-19-03
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 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
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
T100340651
12) Insurance Coveraan: (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 anolications and vermits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 = $20.00
$25.00
A2. /Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 1.f. = $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.£ = $30.00
900 I.f. ~ $0.30 = $270.00
Additional
D. Excavations 5' in depth and over:
0-100 I.£ = $50.00
l.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 = $345.00
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.
SUPE~NT OF HIGHWAYS
*Ol~q OF SOIdCI'HOLD, NEW
Received by the Town Clerk '/OZ~//~.~
Permit Issued /~.~(.~e/~ ~_~ Date
Permit No.
/ Date/
Note: Permit expires one ( I ) 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
~!,NOV.-i~O3(M~N) i6:04 BU GAS DESIGN PATCH TEL:S16 75851~6 P, O04
KEYSPAN//~:'4"'~
EQUES"I"FOR ~I:REET OPENING PERMIT,
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'~' ,,2,
-~o' o3 (MON)
16:05 BU GAS DESIGN PATCH
TEL:516 7855136
P, 005