HomeMy WebLinkAboutMarys RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/24/07
* * * RECEIPT * * *
Receipt#: 8907
Transaction(s):
1 1
Permits
Reference Subtotal
516 $170.00
Check~:8907
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 516
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.#TlOO??l:~tJlhOId Iowa Clerk
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
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) Marys Road Mattituck Name of Owner of Premises Address
Marys Rd- 2- bellholes and a 100' trench trench in the W/s grass area~ approx. 220' s/o
Wickham Ave. to install a gas main and service to house #2505.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
~)
Plumber's License No.
Signature
07/18//07
Date
a) Attachpl~tplansh~wingl~ca~i~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) ~~rkc~veredbythisapp~icati~nmayn~tc~mmencebef~reissuance~faHighwayExcavati~nPermit
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:
Comoletion Date
D-39
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 enDlications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.00
(plus $30.00 trench fee
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 l.f. =$10.00 -
l.f. ~ $0.I0 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If~ .30 = 746 fi of trench ~ .30
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.~ @ $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 = .~/'70~.P"~
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
SUPE~NDENT OF HIGHWAYS
· o [ ou?o%¢tw
Peter W. Harris
Received by the Town Clerk '~/z ~o7
~¢ Date
Permit Issued 7 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 Page 2 of 3
Cot~v Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
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- lnspectorholding forfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN
REQUEST FOR STREET OPENING pERMIT
n-~ STATE [-~ NASSAU SUFFOLK
MIS JOB ·
I.o. '7~07 71~ I DATE _ .
,
I , 7//~/~ 7
GAS CONSTR. MAINT. & SERVICES
TOTAL P.02