HomeMy WebLinkAbout685 McCann LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/27/08
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt~: 20054
Reference Subtotal
560 $205.70
Check#:15088
Total Paid: $205.70
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 560
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
R~C~IV?~D
Ref.#T10087529~ .
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 Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVII,!,E. NY 11801
Name of Applicant
2) McCann Lane Greenport
Address
Name of Owner of Premlses
685 McCann La., - 2 bellholes and a 120' trench in the E/s ~rass area approx. 25' n/o Sutton PI,
to install a I~as 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.
4) Builder's License No.
Electrician's License No.
s)
Plumber's License No.
Other Trade's License No.
Date
u) Attach plot plan showing locution of proposed excavution and relationship to ndjoining premises or
publie streets or urens, nnd giving a detailed descriptiou 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 Cleric
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
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy g
c) State whether policy of cerfitlcation on file with the Highway Department:
d) Coverage required extended to the Town:
13) Security:
a)
h)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for auulications and permits: 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 bellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional If ~ .30 = 120 ft of trench ~ .30
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 = $205.70
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 Issued ~7l'7/'Q~/ Date Permit No.
SUPER~-T~DENT OF HIGHWAYS
TO~q OF SJ~UTHOLD, NJ}W/YORK
- ~ter ~ R~is -
~Date /
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 Page2 of 3
Coov Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S REcoRD
Inspection Date
Findings(usecode)
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 Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
P
HO,
t.OOATION
REASON FOR
OPE~IING
W.O~PA
NO,
REC~IESTED
BY
REQUEST FOR ~TREI~? OPEninG PERMI?
· (~:)UNTY [] SUFFOLK
Fum:~IAN ' ' DATE OF
I ~S COI~TF~ I~LO, JNT. & SERVIC~ .
TDTRC P. 02