HomeMy WebLinkAbout1095 Village LnFile No. '7~
TOWN OF SpU~'HOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765~3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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,
ordinhnces or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinhhces, codes and regulations, and to permit
authorized inspectors to ~akeI necessary.,inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 448 EAST MATN STREET ~ATCHOGUEt N~r YORK 11727
2)
3)
5)
6)
7)
8)
9)
10)
11)
Name of Applicant
Name of Owner Of Premises
Address
Address
1,0c/3'- - '
work D~scription and l_orm~tion (Street Number, Hamlet, Cross Street)
(a) Is construction located within ~S feet of tidal wetlands? *Yes
*if yes, other~T~wn permits may be required.
Builder's License No. Plumber's License No.
No
Electrician's License No.
Other Trade's License No.
Signature of Ap~li~i.~nt
I Z- cYo
Date
a)
b)
c)
Tax Map:
Attach plot plan showing location of proposed e~cavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation. . .
Attach all other necessary permits and licenses for this project.
Work covered by this applicatioh may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
Section , Block , Lot'
Starting Date: Completion Date
Work Schedule: ,:
Phase
Excavation ....................... ..................
Facility Installation .................................
Backfill & Compaction ..............................
Pavement Replacement ..............................
Under which authority is the applifi~ation made:
Estimated Cost of Proposed Work: $
Completion Date
D-39 Paqe 1 of 3
I2)
13)
14)
Insurance Covera.ge: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
d)
and $50,000 property damage.
Security:
a) Surety Bond or Certified Check provided in the
total amount of $
b) Maintenance Bond providedi 2 years or 3 years
Fees for applications and permits: Basic Application Fee ........ $25.00
AI. / /Service Connections excavations
No.
A2. __/Additional Excavations same service La $10.00
No.
B. Excavations 18" in depth 'oi" less:
0-100 I.f. = $10.00
[.f. La $0.10 - $
Additional
C. Excavations- 1'8" in depth to 5' in depth:
0-100 I.f. = $30.00
.l.f. ~ $0.30 = $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.f. 0 $0.50
Additional
Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Iniury,
E. Utility Repair Excavations 0510.00: $ No.
.Repairs same service La $5.00 = $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to isguance of permit.
TOTAL COST' g
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with,this application.
SUPERINTENDENT OF HIGHWAYS
TOWN)~f SOUTHOLD, NEW YORK
~ Raymohd L. ~obs
Date
Received by the Town Clerk
Date
Permit Issued,, / ~0 Permit No. · Date
Note:
Permit expires one (1) year f~om Date of Issuance.
No work to start without 08 hour notice to the Superintendent of' Highways.
Permit must be available for inspection.
Page 2 of 3
KEYS PA N//~,45
REQUEST FOR STREET OPENING PERMIT
Fc*6m.4 [~ STATE ~'~ NASSAU
COUNTY [] SUFFOLK
cou.TY
PERMIT / MIS JOB DATE
~E~SO~ FO~
W,O./PA
NO,
REQUEST~'
BY
APPROVED
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT,& SERVICES
D~iV _~i.~..oDA TE OF
OPENING
N
7.~
SKETCH
N
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/14/00
Transaction(s):
Permits
Receipt~:
1081
Subtotal
$45.00
Check#: 1081
Total Paid:
$45.00
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: LINDAC Internal ID: 20788
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 12/09/05
* * * RECEIPT * * *
ReceiptS: 5947
Transaction(s):
1
Permits
Reference Subtotal
424 $170.00
Check#: 5947
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 424
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100576655
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
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 1095 Village Lane, Orient Name of Owner of Premises Address
3) Village Lane -beilhole e/s Village Lane~ across the street from the i/o Skippers Lane~ in order to
install a gas service to #1095
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction Iocatedwithin 75 feetoftidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
OtherTra~ ~ J~-'~*~
Signature of Applicant
12-02-05
Date
5) 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 maynotcommencebeforeissuanceofaHighwayExcavafionPermit
by the Town Clerk.
· Block , Lot
Completion Date:
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:
Completion Date
D-39 Page 1 of 3
T100576655
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 = $20.00
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-I00 I.f. - $10.00 -
l.f. ~ $0.10 -
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional lf. @ .30 =
D. Excavations 5' in depth and over:
0-100 I.£ = $50.00
I.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 = $170.00
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.
Received by the Town Clerk
Permit Issue4/o)~O i 1
/-/
SUPERINTENDENT OF HIGHWAYS
To ,ou3 oLD, 77,
Peter W. Harris
Note: 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
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3~
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL Improper lights
ST - Sunken trench or excavation
UTM Unable to measure (due to backfilling)
BUC- Building under Constmction
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR- Ready to Repair
D~39 Page 3 of 3
~ PF, RMIT APPLICATION SKETCH ·
DATE:
LOCATION:
TOWN:
WORK ORDER:
12f2;2~05 11:29:13 AM
1095 VILLAGE LN
ORIENT
TI 00~76/6_~
TO%VN OF HUixTTINGTON
CROS~ ~TREET: SKIPPERS LN
SURFACE:
1Vhc~l~t Road
II-Ieu~e
l~P5
/
4 x 4' Bell Hole
VILLAGE LN