HomeMy WebLinkAbout770 Moores Ln NTown Of Southold
P.O Box 1179
Southoid, NY 11971
* * * RECEIPT * * *
Date: 12/04/03
Transaction(s):
1 Permits
Receipt:
2421
Subtotal
$45.00
Check#: 2421
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 83706
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
Ref.#T100341025
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 Southoid, 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
2) 770 Moores Lane N, Greenport
Name of Owner of Premises
3)
Address
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __
*If yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
Address
Moores Lane N - bellhole w/s Moores Lane, 405' n/o Homestead Wa¥~ Greenporg for a gas service to #770
Work Description and Location (Street Number, Hamlet, Cross Street)
X
s)
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Signature of Applicant
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) At~ach 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.
· Block , Lot
Completion Date:
Completion Date
D-39 Page 1 of 3
T100341025
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee ................. $25.00
Al. 1 /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service ~ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-I001.£ = $10.00
1.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-1001.£ = $30.00 =
__ l.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 I.L = $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 at~ached 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 m issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk / °7'/'~A e-t'
Permit Issued / Permit No.
SUPEPd~YE3~NT OF HIGHWAYS
Not~e: 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
PERMIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
11519f2003 2:11:26 PM
770 N MDORES LN
GREENPORT
T10[84102_~
VILLA GE OF
SrREET: HOMESTEAD WAY
S~.FACE: ~
0
I-I~e~oNO. [
~ x 4' BellHole
N MOOI~S LN