HomeMy WebLinkAbout290 Town Harbor RdPermit No. ~
File No. ~
TOWN OF SOUTHOLD
HIGHVv'AY DEPARTMENT
Pcconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#TI00744863
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 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 oftbe
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVII.! jz.~ NY 11801
Name of Applicant Address
2) 290 Town Harbor Rd. South#Id
Owner of Premises Address
3) Town Harbor Rd. - bellhole on the E/s of Town Harbor Rd. 272' s/o Main Street to
install a gas service at 0290 Town Harbor Rd.
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.
Electrician's License No.
/
s)
X
Plumber's LicenseNo. . / /.//~
Other Trade's License No. ~ / /.--it
Signature of Applicant
4-26-07
Date
a) Atta~hp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremiees~r
public streets or areas, and giving a detailed description of layout of excavation.
b) Al~ach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance #fa Highway Excavation Permit
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 .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Pr#posed Work: $
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 Injury, 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 aDDlications 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. Excav~ions 18" in depth or less:
O-lOO1.£ = $1o.oo-
I.£650.10=
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 I.f. = $50.00
1.£ ~ $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.
SUPERINTENDENT OF HIGHWAYS
T(~OU/~THOLD/,/NEW YORK
Peter W~'l~arris
Permit Issued ~'_ 1~ .~ q DatePermit No.
Note: Permit expires one (1) year from Date of Issuance. No work to stan~ without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
2,~
3~,~
4th
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
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 settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN GAS CONSTR
631 ?58 5136 P.02
~ PERMIT APPLICATION SKETCH
~r~.~, GAS SERVICE
~ SUFFOLK
~ NYS I I COUNTY ~ '""/-0,,~ O~
LOCATION · '2-qlJ '"~LW~)' /.1//l./.i~l)l~ RD
TOW,N ~"owT/,¢o
MAP /oI{-1')- 31~:E
CROSS STREET $[o ~.~.,v A.O
WORK ORDER "7-/00'7
TOTRL P.02
Date: 05/04/07
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt: 8482
Transaction(s):
1 1
Permits
Reference Subtotal
505 $170.00
Check#: 8482
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 505