HomeMy WebLinkAboutWest Creek AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 12/06/07
* * * RECEIPT * * *
Receipt"g: 1315
Transaction(s):
1 1
Permits
Reference Subtotal
535 $200.00
Checlc#:9632
Total Paid: $200.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 535
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
REiC E IV,~tJ~)
Re£#T100819996
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) KEYSPANENERGY-GASCONSTR. DEPT. -175E. OLD COUNTRY RD.- H1CKSVILLE~ NY 11801
Name of Applicant
2) West Creek Ave. Address
Cutchogue
Address
Name of Owner of Premises
West Creek Ave. -bellholes and a 100' trench in the N/s grass area~ approx. 120' southeast of
Dicks Pt. Ave.~ to install a gas service and main to house #2705 West Creek Ave.
4)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes
*lfyes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
No X
Plumber's License No.
Other Trade's~~.~~License __
Signature of Applicant
11/30/07
Date
5) a) AHachp~~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 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) 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:
D-39
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
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $20.00 =
100' trench fee
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
+ 20.00 bellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 1.f. = $10.00 -
l.f. @ $O. lO =
Additional
C, Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional lf~ .30 = 746 fi of trench ~ .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 -- $200.00
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
Date
Permit Issued /~. ~' ~' --O 7 Permit No.
SUPERINT~2~DENT OF HIGHWAYS
TO ,~/.~~,. $~
Peter W. Harris
r 15a~e
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:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
i~t
2nd
3rd
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 final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
NOV-~8-2007 09:5? KEYSPAN GAS CONSTR ~1 ?58 51~ P.05
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