HomeMy WebLinkAbout350 Pequash AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/23/08
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt~: 16540
Reference Subtotal
550 $170.00
Check#: 10383
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville NY 11801
Clerk ID: LINDAC Internal ID: 550
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
Ref.#T100867177
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Sonthold 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 TYDe
1) NATIONAL GRID- GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD.- HICKSVILLE~ NY 11801
Name of Applicant Address
2) Pequash Avenue Cutchogue Owner of Premises Address
3) S/s Pequash Ave. - 1-4'x4' hellhole on the S/s, approx. 78' northwest of Ist St., to install
gas service
4) tidalwetiands? *Yes No__X__
*If yes, other Town permits may be required.
Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's e'o~
License No.
SignatUr
Date
5) a) Atta~hp~~tp~ansh~wing~~~ati~n~fpr~p~sedex~avati~nandre~ati~nshipt~adj~iningpremises~r
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 _, Block
7) Starting Date: Completion Date:
., Lot
8) WorkSchedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
I1) Remarks:
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)
Sureiy 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. _l~/Service Connections excavations ~ $20.00 =
$150.00
$20.00
/Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.O0-
I.f. ~ SO. lO =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $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 attached to this application prior to issuance~ ~of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Tom of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ~/t'_ ~9 ~ ~ O ~
Date
Permit Issued ~'t/~ ~i~ ~ - Q ~ Permit No.
SUPER][lCT~'a~DENT OF HIGHWAYS
Peter W. Harris~a
' 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 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
2nd
4th
Findings (use code)
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 - Workin 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
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
NASSAU SUFFOLK
;C-~ll~.4
PERMIT ' ' "MIS JOE
REASON FOR
w.o~.,
RE~ESTED DEPA~MEN~ DIVISION
~ppRov~
TOTAL P. 132