HomeMy WebLinkAbout470 N Bayview RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/10/07
* * * RECEIPT * * *
Receipt~: 9268
Transaction(s):
1 1
Permits
Reference Subtotal
520 $170.00
Check~:9268
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 520
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
R~CEIVED
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR ~. ,.~, · j
Re£#T100801233
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South#Id for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South#Id, Suffolk County, New York, and other
applicable laws, ordinances or ~egulatlons 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 TYne
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant Address
2) 470 N Bayview Rd. South#Id
Owner of Premises Address
4)
4)Builder's License No.
Electrician's License No.
3) W/s of N. Bayview Road approx. 528' s/o Pine Neck Rd. to install a gas service at 0470 N.
Bayview Rd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes No X__
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's ~o~
License No.
g PP
10-03-07
Date
5) a) Atta~hp~~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:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Pr#posed Work: $
11) Remarks:
Block ., Lot
Completion Date:
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~nlications and permits: Basic Application Fee
Al. I /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 -
l.i~ ~ $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
I.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
Permit Issued /0 -/0' 0 ~ Permit No.
SUPERINTENDENT OF HIGHWAYS
T ~Q~. SOUTHOLI~ NEW YORK
-- -- P~ter W. Harris
Note: Permit expires one (l) year from Date oflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
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
1~t
2~d
4a~
Findings (use code)
Applicant Notified
(To Permit Clerk)
REM~JIKS
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 - Inspector holding for final setilement of excavation
RFR Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATE:
LOCATION:
! OWN:
WORK (~DI~R:
10.,3f2~07 10:5.4:23 AM
430 N BAYVIEW F,D
$OUTHOLD
T100~I233
VILLAGE OF
~.OSS ~REE T: PINE NECK RD
SUF~A~:
MacM~a~RoM
He'~ NO.
4'7O
4' x 4' Bell Hole
N BAYVIEWRD