HomeMy WebLinkAboutPike StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/29/08
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt: 28372
Reference Subtotal
582 $200.00
Check#: 15768
Total Paid: $200.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC internal iD: 582
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
RECEIVED
Ref.#T100918406 So.th~l~ ? ..... ,-
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 oftbe
job site.
Print or Tyne
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD.- H1CKSVILLE~ NY I1801
2) Pike Street
Name of Applicant
Mat~ituck
Address
Owner of Premises Address
3)
4)
Install a 4'x4' bellhole in paved area on S/s and a 100' trench in the S/s I~rass area~ approx. 105'
e/o Mary's Rd. to install a ~as main and service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
No X
Plumber's License No.
Other Trade's License No.
08/26/08
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
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: $
I1) Remarks:
Completion Date
D-39
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the llighway DcpaCtment:
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 annlications and hermits: Basic Application Fee
A 1. /Service Connections excavations ~ $20.00 =
100' trench fee
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
+ 20.00 hellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If~ .30 = of trench
D. Excavations 5' in depth and over:
O-lOO l.~ = $50.00
l.f. ~ $0.50 = $
Additional
NO.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $200.00
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
TOWJWOn~_OUTHOLD, ~V YORK
Peter W! Harris
Received by the Town Clerk ~-/o7 5~/~,~
Permit Issued 87~/o7 ?/~.~j/ Date Permit No. ~ -°c~ ''~
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
l~t
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 Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholding forfinalsetilementofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
PERMIT
LOCATION
REASON FOR
OPENING
FOREMAN
DEPARTMENT
GAS CONSTR. MAIh't'. & SERV CES
TOTAL P.04