HomeMy WebLinkAbout4000 Peconic Bay BlvdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/20/08
* * * RECEIPT * * *
Receipt~: 12032
Transaction(s):
1 1
Permits
Reference Subtotal
542 $170.00
Check#: 9953
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 542
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re~#TI00840164
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. Thc 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
1) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Peconic BayBIvd. Laurel Owner of Premises
Address
3) 4000 Peconic Bay Blvd.~ a hellhole on S/s at the intersection of Delmar Drive to install a
gas service to g4000 Peconic Bay Blvd.
4) tidal wetlands? *Yes No __X __
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
Plumber's License No.
Other Trade's License ~L ~__
Signature of Applicant
2-08-08
Date
a) At~ach 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 beIbre issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion 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: $
11) Remarks:
Lot
Completion Date
12) Insurance Covera~ (Atlach 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 nermits: Basic Application Fee
A I. _l~/Service Connections excavations ~ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
l.~ @ $O. lO =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional If. ~ .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 = $170.00
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
TO
Peter W. Harris
Received by the Town Clerk
! \ t O~te
Permitlssued ~ \q .D_~) PermitNo.
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
Cony Distribution:
W.O,/PA
NO.
REQUF. STED
BY
85:33 KEYSPAN OAS CONSTR 631 ?58 5136 P,84
KEYSPAN
REQUE~ FOR ~ET OPENINO ~RMIT
~ ~ 8UFF~K
FORE~N ' ' DA~ OF ~
/ /
I
TOTAL P, 8,4
Highway Departmem
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~d
3rd
4th
Findings(use code)
Applicant Notified
(To Permit Clerk)
REM-ARKS
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 - Improper backfill (too high) (not sufficient)
HFS- InspectorholdingforfinalsetXlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/06/08
* * * RECEIPT * * *
Receipt~: 11992
Transaction(s):
1 1
Permits
Reference Subtotal
542 $170.00
Cash
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 542