HomeMy WebLinkAbout2 Fred RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/21/07
* * * RECEIPT * * *
Receipt~: 9052
Transaction(s):
1 1
Permits
Reference Subtotal
519 $170.00
Check~: 9052
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 519
Permit No.
File No.
TOWN OF SOUTHOLD
H1GHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100782271
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 Yorl~ 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 Applicant Address
2) 2FredRoad
New Suffolk Owner of Premises Address
4)
E/s grass area, aoorox. 38' n/o Fannim, Rd. to reconnect a gas service at #2 Fred Rd.
3)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
Plumber's License No.
4)Builder's License No.
Electrician's License No.
X
Other Trade's~ ~
Sign~ure of Appl~ant
8-15-07
Date
5) a) Attachpl~tplansh~wingl~cati~n~fpr~p~sedexcavati~nandrelati~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 ., Lot
7) Starting Date: Completion Date:
8) Work Schedule:
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 aoolications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.oo
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
i.c @ $0.1o =
Additional
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
LC @ $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,
uDENT OF HIGHWAYS
oLD,
Peter W. Harris
Date
o'~-,,.h~, -o 7
Received by the Town Clerk
Permit Issued oO -,~/- o ~ Date
Permit No.
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
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2ha
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 settlement of excavation
RFR Ready to Repair
D-39 Page 3 of 3
KEYSPAH GAS C_H~TR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
631 ?58 51Z6 P.02
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W,O,/PA
NO.
REQUESTED
BY
APPROVED
SKETCH
~---~STATE r-~ NASSAU SUFFOLK
COUNTY F~ COUNTY
FORE~AN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
DATE OF
DIVISION
DATE
N
TOTAL P.02