HomeMy WebLinkAbout2755 Boisseau AvePermit No.
File No.
5o95
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00804207
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. - HICKSVII,I,I~ NY 11801
Name of Applicant Address
2) 2755 BoisseauAve., Southold Owner of Premises
Address
3)
4)
5) tidal wetlands? *Yes
4)Builder's License No.
Ws grass area~ approx. 295 s/o Yennecott Dr., to repair a gas leak at #2755 Boisseau Ave.
No X
*If yes, other Town permits may be required.
Plumber's License No.
Electrician's License No.
Other Trade's License No.~ ~ ·
Signature of Applicant'
10-15-07
Date
5) 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 , Block , Lot
7) Starting Date: Completion Date:
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:
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
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anvlications 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. Excav~ions 18"indepthorless:
0-1001.£ = $10.00-
1,~$0.10=
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional If. ~ .30 =
D. Excavations 5'in depth andover:
0-1001.fi = $50.00
1.£~$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.
Permit Issued ~ Permit No.
SUPERINTENDENT OF HIGHWAYS
Peter W. Harris
Date
Note: Permit expires one (l) 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
2~
3rd
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- Inspec!orholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
FILE No.277 10/10 '07 06:41 ID: FAX: PAGE 4/ 4
NO.
LOCATION
REASON FOR
OPENING
W. OJPA
NO.
REQUEsteD
BY
APPROVED
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
~'~ STA"rE ~-'~ NASSAU
COUNTY ~ SUFFOLK
COUNTY ~ ~
IDIVlSlON
DATE
SKETCH
~g/~,/£gz~7'--r ])g, /~7-/J'
/.r-- N
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/24/07
* * * RECEIPT * * *
ReceiptS: 9354
Transaction(s):
1 1
Permits
Reference Subtotal
525 $170.00
Check~: 9354
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 525