HomeMy WebLinkAbout4300 Stillwater AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 12/11/07
* * * RECEIPT * * *
Receipt#: 1425
Transaction(s):
1 1
Permits
Reference Subtotal
536 $170.00
Check#: 9603
Total Paid: $170,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 536
Permit No./ ~ ~ TOWN OF SOUTHOLD RECEIV:'D
~J HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic, New York 11958 '
(631) 765-3140 ~'
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100819572
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
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVI1.LI~; NY 11801
Name of Applicant
2) 4300 Stillwater Avenue Cutchogue
Address
Owner of Premises
Addr~s
3) W/s Stillwater Avenue approx. 317' s/o Track Avenue to install a gas service at #4300
Stillwater Ave.
4) tidal wetlands? *Yes
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 L~__
11-27-07
Date
5) 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 ,Block , Lot
7) Starting Date:
8) Work Schedule:
Completion Date:
Phase
Facility Installation ...............................................................
Backfill & Compaction .........................................................
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) Coverage required extended tothe Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 properly damage.
13) SecuriW:
a)
Surety Bond or Certified Check provided in the total amount
ors
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
$20.0o
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.£. =
Additional lf. ~ .30 =
D. Excavations 5' in depth and over:
0-100 Lf. = $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.
Received by the Town Clerk /c~-/J--O ~
Date
Permit Issued .]c~-/t/ -O ~) Permit No.
SUPE~qDENT OF HIGI~WAYS
v v - ~ Peter W. Harris
! Dato
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
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~d
3~
4th
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 -lmproper backfill (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION ~KETCH
DATE ~
LOCATION:
T OWN:
WORK CRDER:
11/27;3t007 8:27:17 AM
4300 $ T/LLWATKR AVE
CUTCHOGUE
T100519~72
VILLAGE
CROSS b'TREET: TRACK AVE
~O'P-~'A C~;
M~cM~auRoM
NO.
43~0
4' x 4' Bell Hol~
317'
ST[LLWATER AVE