HomeMy WebLinkAboutCases LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 12/06/07
* * * RECEIPT * * *
Receipt: 1313
Transaction(s):
1 1
Permits
Reference Subtotal
533 $170.00
Checl~: 9634
Total Paid: $170,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 533
Permit No.
File No.
/ f) % TOWN OF SOUTHOLD
.~] ~ HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958 (631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR $ot~f~o[J T6~,Tn C[o~k
ReL#TI00819398
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South#Id for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South#Id, 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
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) Cases Lane Cutchogue Owner of Premises Address
3)
4)
Builder's License No.
Electrician's License No.
E/s Cases La.~ (grass area)~ approx. 52' s/o Main Rd, to re-install gas to bldg. 027550
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No.
11-30-07
Date
a) Attach plot plan showing location of pr#posed 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
5)
by the Town Clerk.
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated CostofProposedWork: $
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 to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property 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 nermits: Basic Application Fee
Al. _i__/Service Connections excavations ~ $20.00 =
$150.00
$2o.oo
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 Lf. = $10.00 -
l.f. ~ $0.10=
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPER,,IJaq~DENT OF HIGHWAYS
t/ -- - Peter'S/. H~rlS -
Received by the Town Clerk / ~ - 6, - 0 7
Date
Permit Issued ],~ -/~ ~0 ~' Permit No.
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB- Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
I)-39 Page 3 of 3
NOU-28-2007
06:37 KEYSPAN BAS CONSTR 63i ?58 5i36 P,02
K£YSPAN
RBQU£$T ~OR STREET OPENING PI:RMIT
LOCATION
REASON FOR
OPENING
W,OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
E~' STATE F"J NASSAU SUFFOLK
FOREMAN
DEPARTMENT '
GAS CONSTR. MA NT.& SERVICES
JDATEOF
DIV~ION
DATE
"1