HomeMy WebLinkAbout19725 Soundview AveTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/04/03
Transaction(s):
1 Permits
Receipt~:
2430
Subtotal
$45.00
Check#: 2430
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 83708
Permit No.
File No.
PERMIT FOR EMERGENCY GAS LEAK REPAIR
TOWN OF SOUTHOLD
HIGH~VAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100341856
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 CONSTIL DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE_ NY 11801
Name of Applicant
2) 19725 Soundview Avenue~ Southold
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
5)
Address
Address
Soundview Avenue - bellhole s/s of Soundview Avenue 275' e/o Chablis Path~ for a gas service to #1972q
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*lf yes, other Town permits may be required.
Plumber's License No.
Other
Tra~ License N~. ~
?
~Signat~re of Apl~ictnt
11-21-03
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) ARach 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
7) Starting Date:
8) Work Schedule:
, Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
D-39 Page I of 3
T100341856
12) Insurance Coverage: (At~ach 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 ant~lications and permits: Basic Application Fee ................. $25.00
Al. I /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 l.f. = $10.00
l.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 =
__ l.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $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 $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.
SUPERINTENDENT OF HIGHWAYS
TOJ/~q'-~OUTH OLD, NEW XORK
Peter W. Harris
/
/
Date'
Received by the Town Clerk /o~
Permit Issued / C// ,~ Permit No.
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
~ PF. RM~T APPLICATION SKETCH
DATE:
LOCATION:
TO~T~:
WORK ORDER:
I1/21/2003 11:27:39 AM
19725 SOUND VIEW AVE
SOUTHOLD
T10~34I~6
VILLAGE OF
~JRFACE:
I'-Ie we NO.
19725
~ x 4~ BellHole
SOUND VIEWAVE