HomeMy WebLinkAbout365 Harper Rd WTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/10/07
* * * RECEIPT * * *
ReceiptS: 9262
Transaction(s):
1 1
Permits
Reference Subtotal
522 $170.00
Check#: 9262
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 522
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECEIV~-D
Ref.#TlOOSOIlJ~l~ojd ?~.~n C~rk
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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant Address
2) 365 Harper Rd W. Southold Owner of Premises Address
3) N/s of Harper Road W. approx. 257' w/o Wells Road to install a gas service at #365
Harper Rd. W.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __
*lf yes, other Town permits may be required.
4)Builder's License No.
Electrician's License No.
$)
X
Plumber's License No.
Other Trade's License No.
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 covered by this application may not commence before issuance of a Highway 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 Cost of Proposed Work: $
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 at>vlications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 =
$150.00
$20.0o
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
I.f. @ $0.10 =
Additional
C. 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.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 /t~- ~:~'--0 7
Permit Issued /t:9 ~/'O '~O .~Date Permit No,
SUP~I;h[TENDENT OF HIGHWAYS
TOWN OF SOUTHOLD,.I~EW YORK
Peter W. Harris
t, Da~
Note: 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
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
~ODE
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- lnspectorholdingforfinalsetfiementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION ~K~TCH
DATE:
LOCATION:
T OWN:
WORK
10;2/2~? 8:37:57 AM
365 HARPERRD Vl
$OUTHOLD
T100~0549
VILLAGE OF
S'~REE T ~ '~IgLL~ RD
SUF~FAC~;
Macad~n Roacl
365
4' x 4' Bell Hole
HARPER RD W