HomeMy WebLinkAbout650 Old Harbor RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/02/07
* * * RECEIPT * * *
Receipt~: 8849
Transaction(s):
1 1
Permits
Reference Subtotal
513 $170,00
Check~: 8849
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 513
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REI~AIR' ~ * ~
Ref.#T100767224
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
j ob site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVll J,E~ NY 11801
Name of Applicant Address
2) 650 Old Harbor Road New Suffolk Owner of Premises Address
3) W/s Old Harbor Road 680' s/o New Suffolk Road to install a gas serviceat 650 Old
Harbor Road
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4)Builder's License No. Plumber's License No.
Electrician's License No.
Other Tr~__
6-26~}7
Date
5)
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
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
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated CostofProposedWork: $
11) Remarks:
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 lnjury, and $50,000 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. _l~/Service Connections excavations ~ $20.00 =
$150.00
$20.oo
A2. /Additional Excavations same service ~ $10.00
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
L£ @ S0.10 =
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
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 at~ached 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 ~'- '~- O 7
Date ~--/,~
Permit lssued ~7 - Z - O 7 Permit No.
SUPERINTENDENT OF HIGHWAYS
TOWN 9~'~JOTHOLD, NF~W YORK
Peter ~. Harris
/ Dat~
Note: Permit expires one (1) year fi.om Date of Issuance. No work m start without 48 hoar 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
l~t
2nd
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 - Workin Progress
DB Improper backfill (too high) (not sufficient)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION 5KETCH
DA!E:
LOCA~IOPI:
TOWN:
WORK ~DER:
f¢2~/2~07 2:26:43 PM
OLD HARBOR RD
I~EW SUFFOLK
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Maca~a~ Ro~i
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OLD HARBOR P..D