HomeMy WebLinkAbout230 Kimberly LnTown Of Southold
P,O Box 1179
Southold, NY 11971
Date: 11/08/07
* * * RECEIPT * * *
Receipt~: 9478
Transaction(s):
1 1
Permits
Reference Subtotal
529 $170,00
Check~:9478
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 529
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100813090
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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTIL DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY ! 1801
2)
3)
4) tidal wetlands? *Yes
Builder's License No.
Electrician's License No.
5)
Name of Applicant
230 Kimberly Lane Southold
Address
Owner of Premises
Address
W/s Kimberly La. (gas main on E/s)~ approx. 202' s/o Pine Neck Road to install a ~as
service to 0230 Kimberl¥ La.
No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No.
11-05-07
Date
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
7) Starting Date:
8) Work Schedule:
, Block ., Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of cettification 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) SecuriV/:
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 oermits: Basic Application Fee
Al. _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 l.f. = $10.00 -
I.f. ~ $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 I.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 -- $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPER1N~X~DENT OF HIGHWAYS
TOW 05 yTH D,
.... Peter W. H'ar~i~ -
Date
u-g-oq
Date
Permit No. ~q,
Received by the Town Clerk
Permit Issued
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
4·
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backtill (too high) (not sufficient)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATE:
LOCA~ ION.'
TOWN:
WORK
11/$/2107 10:07:26 AM
~0 KIMBERLY LN
SOUTHOLD
T100813~0
VILLAGE OF
CROSS S'FRI~ET: PINE I~ECK RD
~J F~A CE:
I-I~ NO.
220
4' x 4' Bell Hole
KIMBERLY LN