HomeMy WebLinkAbout380 1st StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/11/07
* * * RECEIPT * * *
ReceiptS: 9021
Transaction(s):
1 1
Permits
Reference Subtotal
524 $170.00
Check~: 9021
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 524
Permit No.
File No.
RECEIVED
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT ~ _
Peconic Lane ~/f~, .7 ,7 2007
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100777655
APPLICATION IS HEREBY made to the Superintendent of Highways of thc Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 8.] 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 Appli~a#~ Address
4)
2) 380 pt St. New Suffolk Owner of Premises Address
3) W/s Ist Street 68' n/o Jackson Street to retire a gas service at #380 1st Street
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4)Builder's License No.
Electrician's License No.
5)
X
Plumber's License No.
Other Trade's License No. __
8-08-07
Date
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) Attach all other necessary permits and licenses for this project.
c) Work ~'overed by this application may not commence before issunnce nfa Itighwzy 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 CostofProposedWork: $
11) Remarks:
Completion Date
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: 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 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
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 gxanted 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 /6.D'-/t'j O '7
Date
Permit Issued / t9 -/[ -69 ~ Permit No.
SUPERINTENDENT OF HIGHWAYS
TOW~_~,~C ) ~~SOUTHOLD' ~ W YORK
Peter W. Harris
Date
NQI~: 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
3rd
Findings (use code)
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 -lmproper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
Al IG-O?-2UU? ~D]]~ 4q~ t]E','SPAII GAS C:ON!BTE:
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
,~EASON FOR ~ ,~ ~ ~
~--~ ~OREMAN DATE OF
~D ~ DEPARTMENT J DIVISION
GAS CONSTR, MAINT. & ~ERV[CES
APPROVED
SKETCH
TOTAL. P. 82