HomeMy WebLinkAbout1500 Bay AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/04/08
* * * RECEIPT * * *
Receipt'g: 10907
Transaction(s):
1 1
Permits
Reference Subtotal
541 $170.00
Check#: 9898
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 541
RECEIVED
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00836062
APPLICATION IS HEREBY made to the Superintendent of Highways oftbe 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
1) KEYSPAN ENERGY- GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD.- HICKSVILLE. NY 11801
Name of Applicant Address
2) Bay Avenue E. Marion Owner of Premises Address
3)
install a gas service
4) tidal wetlands? *Yes
1500 Bay Avenue~ opening a bellhole on W/s approx. 150' n/o Lakeview Terrace, to
Builder's License No.
Electrician's License No.
No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's~ ~.~~..License P __
Stgnature of Apphcant
12-28-08
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all uther 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 , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d)
13) Security:
a)
b)
Coverage required extended to the Town:
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 annlications and permits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 =
$150.00
Sz0.0o
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
1.£ @ $0.10 =
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
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 aitached to this application prior to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to ~he 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 t ~/t'///
Permit Issued ~/~///1~ ~ Date
SUPEJ~TENDENT OF HIGHWAYS
TO~/N~~O THOL EW YORK
eter W. Harris
Date
Pe itNo.
Not~e: Permit expires one (I) yea~ 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
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
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
W1P Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholdingforfinalsetilementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
140,
L.O~ATION
REASOFI FOR
OPENING
W. OJPA
I~10.
BY
KEYSPRN ~ CONSTR 6~1 758 51~6 P.~4
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
[] STATE [] .A.AU
O0~NTY [] SUFFOLK
DEP*R~4ENT IDIVI,ON
GA800NgTR. M~INT. & SERVIC~
1