HomeMy WebLinkAboutPath WayTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/05/08
* * * RECEIPT * * *
ReceiptS: 27013
Transaction(s):
Permits
Reference Subtotal
575 $200.00
Check
Total Paid: $200.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: L1NDAC Internal ID: 575
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
5 L 08
Ref.#T100901941
Southold Town Clerk
APPLICATION 15 HEREBY made to the Superintendent of Highways of the Town of $outhold for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe 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
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
2) PathWay
Name of Applicant
Cutchogue
Address
Name of Owner of Premises
4) Builder's License No.
Electrician's License No.
3) 1145 Path Way - 2 bellholes and a 100' trench in the N/s grass area approx. 20' e/o Fairway Dr,
to install a gas service and main.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No.
07~28~8
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 may not commence before issuance ora Highway Excavation Permit
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: $
Il) Remarks:
Completion Date
D-39
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy ti
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) SecuriP/:
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. /Service Connections excavations ~ $20.00 =
100' trench fee
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
+ 20.00 bellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 l.f.: $10.00-
Lf. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If ~ .30 = 100 ft of trench
D Excavations 5' in depth and over:
0q00 Lf. = $50.00
L£ @ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $1600 = $
Repairs same service ~ $5.00 ~ $
Notice to public utilities proof must be provided and aitached 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.
Received by the Town Clerk ~ - ,9-- 19 ~
Permit Issued ~- ....'5~- O ~ Permit No.
SUPERIN~a.!~ENT OF HIGHW)YS
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
4th
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - 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 -lmproper backfill (too high) (not su~cient)
HFS Inspector holding for final settlement of excavation
RFR Ready to Repair
D-39 Page 3 of 3
TOTAL P. 18