HomeMy WebLinkAbout75 Bray AvePermit 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£#T100806283
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 11801
Name of Applicant Address
2) 75 BrayAve., MaHituck Owner of Premises Address
3) Ws Bray Ave., approx. 320' n/o Peconic Bay BIvd.~ to install a gas service at #75
4) tidalwetlands? *Yes No X__
Builder's License No. A//~ yes' °ther T°w n @:ium:Sbemr~: ~::qn:~d~. ~
Electrician's License No. / "/ / ~ Other Trade's License I
5)
Signature of Applicant
10-17-07
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 appllcation may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section ,Block
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 Cost of Proposed Work: $
11) Remarks:
, Lot
Completion Date
12) Insurance Coverage (At~ach 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) SecuriW:
a)
b)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 pmpe~y damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for aDnlications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 =
$150.00
$20.oo
3,2. /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:
o-too ~.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.
Received by the Town Clerk 16 ~ ~q
Permit Issued l~} ' .t~"O'"'} DatePermit No.~
SUPERJlq-~ENDENT OF HIGHWAYS
TOW~ OF~OUTHOLD, gEW YORK
~ Peter~V¢. Harris
Noto: Permit expires one (1)year from Dateoflssuance. Nowork tostartwithout48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
Coov Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~d
3rd
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper Iights
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 settlement of excavation
RFR - Ready to Repair
D-39 Page 3 of 3
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.IPA
NO.
REQUESTED
BY
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
r-]STATE [~ NASSAU
COUNTY
SUFFOLK
oou.TY
MIS JOB ~ ~ JDATE
FOREMAN DATE OF
DEPARTMENT
GAS CONSTR. MAINT.& SERVICES
APPROVED
DIVISION
DATE
SKETCH
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/24/07
* * * RECEIPT * * *
Receipt'8: 9372
Transaction(s):
1 1
Permits
Reference Subtotal
526 $170.00
Check~: 9372
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 526