HomeMy WebLinkAbout2225 Calves Neck RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/02/08
* * * RECEIPT * * *
Receipt: 14846
Transaction(s):
1 1
Permits
Reference Subtotal
548 $170.00
Check~: 10193
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 548
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pecooic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100856119 ~
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
l) NATIONAL GRID- GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 2225 Calves NeckRoad Southold
Owner of Premises Address
3) Calves Neck Rd. - bellhole w/s Calves Nk Road 475' e/o Harper Rd.
4) tidalwetlands? *Yes No __X
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
Plumber's License No.
5)
Other Trade's License No.
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:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
Il) Remarks:
Block , Lot
Completion Date:
Completion Date
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. _l__/Service Connections excavations ~ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excav~ions 18"indepthorless:
0-1001.£ = $10.00-
1.£~$0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional I£ ~ .30 =
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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Pannit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk /--/-2 ~ t:9 oO
Date
Permitlssued C/'~ O.,~,Og~ PermitNo. ~-~ goE')
SUPERINTENDENT OF HIGHWAYS
· o o HoLc/) w YOR :
Peter ~V~ Ha~'is
Not__e: 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
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 -lmpmper backfill (too high) (not sufficient)
HFS- Inspector holding for finalsetilementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
SUF~ACE.'
Macadam Roi
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LOCATIa~:
OWN.-
W Ot~.K ORDER~
PI~ API~IC~TION SKi~TCH
Village Of
3/28/2008
2225 CALVES NECK li~bss sy~eeT n
SOUTHOLD ~oss s~ee~r :,
T100856119
HARPER RD
HARPER RD
2225
4' x~4' Bell Hole
475'
CALVES NECK RD
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