HomeMy WebLinkAbout800 West Bay DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/06/07
* * * RECEIPT * * *
Receipt~: 8338
Transaction(s):
1 1
Permits
Reference Subtotal
498 $170.00
Check~:8338
Total Paid: $170~00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 498
Permit No.
File No.
(q
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEIVED
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#TI00737258
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) 800 West Bay Drive Cutchogue Name of Owner of Premises Address
3) West Bay Drive (West Rd) - belholle on the S/s 174' e/o Holden Avenue to install a gas
service to #800 West Bay Dr.
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 ~o.
5)
Plumber's License No.
Other Trade's License No.
Signature of Applicant
4-03-07
Date
a) Attach~~~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 maynotcommencebeforeissuanceofaHighwayExcavationPermit
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 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 prope~y damage.
I3) Security:
a)
Surety Bond or Certified Check provided in the total amount
nfS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and permits: Basic Application Fee
Al. _l~/Service Connections excavations ~ $20.00 =
$150.00
$20.o0
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
I.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
l.f. ~ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
iqotice 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 z.~/- ~, , O 7
Date
Permit Issued </g - ~, - O P Permit No. Lt/ ~a(~
SUPERINTENDENT OF HIGHWAYS
TOWbkOP~OUTHOLD, NEW/YORK
P ete,r~ H//ar~is
f ~ Elate
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
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
lst
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- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
"~ ~BERMIT. APPLICATIO~ SKETCH
E~.. GAS SERVICE
P. 02
~ NYS ~ SUFFOLK
COUNW
DATE
LOCATION
TOWN
MAP /0(
CROSS STREET /''') ~/
WORK ORDER
SKETCH
T-/oo73-/UP
TOTAL F'. 82