HomeMy WebLinkAbout1455 Sound DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/11/07
* * * RECEIPT * * *
Receipt~: 9281
Transaction(s):
1 1
Permits
Reference Subtotal
523 $170,00
Check~: 9281
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 523
Permit
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl00801'200 ~' C~r~l
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. - HICKSV1LLE. NY 11801
Name of Applicant Address
2) 1455 Sound Drive Greenport Owner of Premises
Address
a)
4)Builder's License No.
Electrician's License No.
S/s grass area~ approx. 100' e/o Inlet Pond Rd. to install a gas servie at #1455 Sound Dr.
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's L~ ~__
Signatur~ of Applicant
10-08-07
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) 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
7) Starting Date: Completion Date:
8) Work Schedule:
, Lot
Phase
Facility Installation ...............................................................
Bacilli & Compaction .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Coverage (A~.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:
Bodily injury and properly 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 annlications and permits: Basic Application Fee
Al. _l~/Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$2O.OO
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 =
Excavations 5' in depth and over:
0-100 l.f. - $50.00
l.f. @ $0.50 = $
Additional
Ho.
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 ~is application.
SUPERINTENDENT OF HIGHWAYS
TQW1;~ SOUfHOLD, N~t/YORK
Peter W. Harris
Received by the Town Clerk /~9-//- O 7
Permitlssued ~'D-t~/-O ~ Date PermitNo. ,,_Q~a2~ ,,~
Date
Note: Permit expires one (l) year ffom Date oflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~
4th
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 - Improper backfill (too high) (not sufficient)
HFS Inspector holding for final setilement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT
NO.
KEYSPAN GAS CONSTR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
I--"] STATE ~ NASSAU SUFFOLK
COUNTY ~] COUNTY
MIS JOB
.o.
?58 5136 P.OR
OATE lelY/w,,"7
LOCATION
REASONFORI
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
..~.~LE:'~' ~-~ i~F(~i~E~AN [~,I..~'~LL ~ ~..~'/IS ..~d4~DATEOF
/
OPENING
DEPARTMENT I DIVISION
~ GAS CONSTR. MAINT. & SERVICES
JDATE
SKETCH
~' / ;; 55
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