HomeMy WebLinkAbout725 Holden AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/19/07
* * * RECEIPT * * *
Receipt~: 8426
Transaction(s):
1 1
Permits
Reference Subtotal
50O $170.00
Check~: 8426
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 500
18/04 '~7 WED 14:28 FAX 63! 765 6145
F~LE No:128 0~18 '07 lO:07~D:
p~rmit N~
File N~
SOUTH01D TOWN CLERK
FRX:
~ Hlghw~v Dept
RECEIVED
TOwN' OF' $OUTHOLD
H~GHWAY DF~ARTMENT ~
P~ic. N~ Yo~ 119~
(~]) ~14o Sout~d Tc¥:n C~erk
~R ~O~AY ~XCAVA~ON ~
~]002 .__
~ 2/ 2
_Rer.#T100741~Io
Pt~ut or ~
1) ~A'~YSPAN ]~P_,.~GY- ~ ~ON ~TR_ D~ri, - I'/S E. ~[~) COUNTRY RD, -H~CKSVJ~.LF~ NY 11~01
2) ~ Belden Awnuc Cut~hogtw Name of Owner of'Premises Addr~s
3) Holdt~ Ayenae - belbaJk on tho W/$ ~flO' a/o Smxtherll C'Fns~ Ro~d ks ius~H a ~
sewice at 72S HoJd~ A~ue
X
Oaer T~de's t,lc,(~ Ne-
Date
by the Tov~ Cler~.
b~ Tt~ Map: ~cfion , m0~k . ~
~ S~rfln8 ~: Cnmpl~n Da~:
8) Work ~h~u[~:
~ · ~mnla~on Date
Fa~i~ ImfaHa~ ...............................................................
hc~ & ~ ......................................................... .,
~ Under wkl~ a~heri~ i~ ~e nppl~fiGn mn~e:
10) ~fima~ Cost of~roposed Wo~k: $ =,
Il) Remarb: .__ .
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 applications and permits: Basic Application Fee
Al. I /Service Connections excavations @ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. - $10.00 -
l.f. @ $o.~o -
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
l.f. ~ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to publlc utilities proof must be provided and atlached to this application pri~r to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit Issued
SUPERINTENDENT OF HIGHWAYS
Peter W. Harris
~/~]atY
7 Permit No.
Not~e: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Cor~v Distribution:
Highway Department
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
3ra
4~
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS - lnspector holding for final settlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
P~RMIT APPLICATION 5I~TCH
DATE:
LOCATION:
TO~:
WOF. K C~DER:
4.,'17."2~? 8:43:10 AM
725 HOLDWN AVE
CUTC I"IOGUE
T100741710
VILLAGE OP
C1~O$S ~1[REET: ~OUTHERN CRO$/: RD
~JI~ACE:
20~
4' x 4' Bell Hole
IHOLDEN AVE
18/04 '07 WED 14:29 FAX 631 765 6145 SOUTIIOLD TOWN CLERK ~001
*** TX REPORT
TRANSMISSION OK
TX/RX NO
CONNECTION TEL
CONNECTION ID
ST. TIME
USAGE T
PGS. SENT
RESULT
3487
97651750
Highway Dept
18/04 14:28
00'50
2
OK
FI~ ~o.1~ 0~/18 '07 10:07 ID:
' D~tivery-
Energy.. . ",
FAX:
CO,
.]
FILE No.t28 04/~8 '07 ~0:07 ID: FRX: PflGE 2/ 2
Permit No.
File No.
TOWN OF $OUTHOLD
i~GI~vVA¥ DEPA.RTMENT
Peoonie Lane
Peco~ic, New York 11958
(~31) 76.~-3140
AI~pLICATION/PERMIT FOR HIGltNVAY EXCAVATION AND REPAIR
kef. fiT100741710
APPLICATION iS ~REBY made W the Sul~=6nteodees of H~hways of the T~n ~ ~utb~d for the issuanc~ of
ap g~a~fica pe~t pu~UaOt te Ch~par ~ of thc Code of the Town ~ ~a~old. SuffOlk Co~nW, New Yor~ and other
appll~ble law~ ordina~ or ~latlo~ for ~e ex.video hes~u de.rind. The appll~nt a~rm ~ ~0mpiy wi~ afl
appli~ble laws, ordinane~ ~ and r~ulati0aa, ad to ~rmit an~or~ [nspcmfl ~ ma~ n~W in~om of the
job si~,
1) KI~YSPAN ~,NERGY- G.dS CONS'IR. DEWf. - 175 E- OLD COUNTRY RD, - H{CKSVILLF,, NY 11801
Nam~ of Applicant Address
2) 72SHeldon Avnnue Cutchogu~ Name of Owner of Premises Address
3) Holden Av~nOe - b~lholla on the W/s 200' n/o Southern Cross Ro~d to install
service Bt 72~ Holden Avenue
4) Work Description and Lo~ation (Street Number, Hamlet, Cross Stree0
(a) I~ c0Ostruction I~at~d withio 7S f~t of ~dal wetlands? 'Y~s No
'If yes, otb~ Town permib may b~ ~ir~.
4)Builder's Li~nse No. Plumber'~ Licen~ NO.
~[~rietan's Li~nze NO.
X
Othar Trade's License No-
SignAture of Applicon
Date
6) Tax Map: Section
7) Starting Date:
a) Affaeh plot plan showing location of proposed ezcavation and relationship to adj°ining pr~mises °r
public stree~ or areas, and giving c detailed dmcripfioa of layout of cxcevation.
b) A,oeh all other necessary permi1~ and licenses for this project.
c) Work covered by this application may not commence boform issuance ore Highway Excavation Permit
by the Town Clerk.
, Block , Lot
Comple~ion Date;
8) Work Schedule:
E~eav~tion .........................................................................
Fa~iity Installation .........
~aekflll & Compaction ..........................................................
Pavement P. olacement .........................................................
9) Under wbleh authority i~ the applicatinn made:
Estimated Cost of Proposed Work: $.
!1) Remarks:
12) ] nsuranc~ Cowralu~ (Atte~h Copy)
a) lnsur~e Company: