HomeMy WebLinkAbout1230 West Creek AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/21/07
* * * RECEIPT * * *
Receipt~: 8266
Transaction(s):
1 1
Permits
Reference Subtotal
496 $170.00
Checld~: 8266
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old CountpJ Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 496
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
R~CEW~D
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAII~0tl,~i,,~ ]'~, p. C~0~
Re£#T100732183
APPLICATION 1S 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 oftbe
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 1230 West Creek Ave. Cutchogue Name of Owner of Premises Address
3) W. Creek Avenue- bellhole on E/s 230 s/o North Cross Road to install a gas service to
#1230 West Creek Avenue
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 No.
s)
Plumber's License No.
Other Trade's License No.
Signature of Applicant
3-19-07
Date
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 .,Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase Completion Date
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Coverage (Attach Cop5,)
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
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. ~ $0.10
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional 1£ ~ .30 =
646 Ft of Trench
D, Excavations 5' in depth and over:
0-100 1.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 with this application.
SUPERINTENDENT OF H1GHWAYS
N /ou
Peter W. Harris
Received by the Town Clerk e.i/-~y,,/-~ 7'
Date
Permit Issued ~-02/'- ~ '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
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
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
~ P~RMIT APPLICATION 5I~TCH
DA'rE:
LOCAl' ION:
TOWN:
WORK (~.DER:
~tlgf2~]7 9:20:07 AM
1230 WES T CREEK RD
CUTCHOGUE
T100732183
VILLAGE
CROSS ~ffREET: N CROSS RD
SURFA(~:
M~c.~dam Ro~
230
4' x 4' Bell Hole