HomeMy WebLinkAbout250 Peconic Bay BlvdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/09/07
* * * RECEIPT * * *
ReceiptS: 8524
Transaction(e):
1 1
Permits
Reference Subtotal
506 $170.00
Check#: 8524
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 506
Permit No.
File No.
/ /c,~ //~ TOWN OF SOUTHOLD RECEIVED
,.~ ~,/ U HIGHWAY DEPARTMENT
. Peconic Lane
Peconic, New York 11958 ~!/~¥ ~ 200?
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND ~l~lt~ ]'G¥,ql Clerk
Re£#T100746951
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
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 250 Peconic Bay Blvd. Laurel Owner of Premises Address
3) Peconic Bay Blvd - hellhole- on the S/s of Peconic Bay Blvd. 400' e/o Laurel Lane install
a gas service at #250 Peconie Bay Blvd.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
X
yyes, other Town permits may be required.
4)Builder's License No. //~////A Plumber's License No. /V/fl
Electrician's License No t [ ' Other Trade's License No
5-02-07
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) TaxMap: Section ,Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
I0) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance CoveraRe (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) Securi~:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and penmits: Basic Application Fee
A I. _l~/Service Connections excavations ~ $20.00 =
$150.00
$~o.oo
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or Jess:
0-100 I.f. = $10.00 -
l.f. @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 --
646 Ft of Trench
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 xvith this application
Received by the Town Clerk ~° ~ ~ ~ 7
Date
Permit Issued ~-- ~'- O ~> Permit No.
SUPERINTENDENT OF HIGHWAYS
TO~/~F~ SOUTHOLD, NF~W YORK
Peter W. Harris
...%'-0 6-
Note: Permitcxpiresone(l)yea~ from DateofIssuance. Nowork to start without 48 hour notice to the SuperintendentofHighways.
Permit must be available for inspection.
D-39 Page2 of 3
Coov Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3a
4t~
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB- Improper barricades
1L - 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- Inspectorholdingforfinalsettlementofexcavafion
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION $KETCH
DA!I~:
LOCATION:
TOW/q:
WORK ~RDER:
5/1,'~ 00'/$:~:10 AM
:~0 PECONI¢ BAY BLVD
LAUP,.EL
T100746~$1
VILLAGE OF
4' x 4' Bell Hole
40o'
PECONIC BAY BLVD
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/08/07
* * * RECEIPT * * *
Receipt~: 8735
Transaction(s):
1 1
Permits
Reference Subtotal
509 $170.00
Check~: 8735
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 509
File No. ~/) ~/ I
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECE~J~
dUN 8 ~007
' Southold T~wn Clerk
Re£#T100759457
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 ibc
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - H1CKSVILLE~ NY 11801
Name of Applicant ~C~ Address
2) 250 Peconic Bay Blvd. Lam~ Owner of Premises Address
3)
install a gas service at #9895 Peconic Bay Blvd.
4) 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.
4)Builder's License No.
Peconic Bay Blvd - hellhole - on the S/s of Peconic Bay Blvd. 700' w/o Sigsbee Ave. to
Electrician's License No.
X
Plumber's License No.
Other Trade's License No. a 4,__
~ure of Ap}lica~[
6-05-07
Date
5) 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 , 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 propet~.y 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 applications and permits: Basic Application Fee
Al. _l__/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.~ @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
646 Ft of Trench
D. Excavations 5' in depth and over:
0-100 l.fi = $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 ~ ~ ~'- O 7
Permit Issued ~, ~ ~'~ O ~ Date Permit No. ,J'-/-~'
SUPERINT~[,hl~)ENT OF HIGHWAYS
*ow _2g o NyWb92
Peter W. H~is'- ~
Date
Note: Permit expires one ( l ) year from Date of Issuance. No work to strut 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(usecode)
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 ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION 5I~TCH ;
DATE:
LOCATION:
T OWN:
WORK C~DER:
6/$320~ 11:17:46 AM
9895 PECONIC B AY B LVD
MATTI/'UCK
T100759457
VILLAGE OF
(~.OS~; ~'[RI~E I: SIGSBEE RD
M~e~l~mt RoM
I~u~ NO.
9895
4' x 4' Bell Hol~
PF~CONIC BAY BLVD