HomeMy WebLinkAbout675 Westview DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/01/07
* * * RECEIPT * * *
Transaction(s):
1 1
Permits
Reference Subtotal
527 $170.00
Check~:9434
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 527
Permit No..//
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00810744
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.- HICKSVILLE. NY I lg01
Name of Applicant Address
2) 675 Westview Dr., Mattituck Owner of Premises
Address
3)
4)
Builder's License No.
Electrician's License No.
N/s Westview Drive 435' S/o Brower Rd. to install a gas service at #675
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No. __
10-29-07
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) At~ach 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: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated CostofProposedWork: $
!1) Remarks:
Comoletion Date
12) Insurance Coveraue (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:
13) Security:
a)
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 $
h) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aDtdications and permits: Basic Application Fee $150.00
Al. _l~/Service Connections excavations ~ $20.00 - $20.00
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
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~ @ $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.
SUPE~-~DENT OF HIGI~AYS
Peter W. Harris
Date
//
Received by the Town Clerk ~ //~/~/~
Permit Issued ~_5'~:3~"?-, £5~./)~e~ permit No. .,O~r-"~ ~'
Not~: Pemit expires one ( 1 ) ye~ ~om Date of Issu~ce. No work ~ s~ wi~out 48 hour notice to the Superintendent of Highways.
Pemit must be avMlable for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
3,d
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 - Improper backfill (too high) (not sufficient)
HFS - Inspector holding for final setfiement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
I~RMIT APPLICATION $I~TCH
DAT~:
LOCATION:
TOV~:
WORK (~t DER:
10/29~20078:22:2~ AM
6V$ WESTV]EW DR
MAT'FI'IUCK
T100510744
VILLAGE OF
~OSS STR~ !~ BROWER RD
M~lam Road ~
Howe NO.
435
4' x 4' Ben Hole
V~r_.~TV IEW DR