HomeMy WebLinkAbout950 Town Harbor RdTown Of Southold
P,O Box 1179
Southold, NY 11971
Date: 03/15/07
* * * RECEIPT * * *
Receipt~: 8204
Transaction(s):
1 1
Permits
Reference Subtotal
495 $170,00
Check~: 8204
Total Paid: $170,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 495
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00727494
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 exeavation herein described. The applicant agrees to comply with all
applicable laws, ordinances, eodes 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) 950 Town Harbor Road Southold Name of Owner of Premises Address
3) Town Harbor Road - bellhole on W/s 360' s/o L' Hommedieu La. to install a gas service
to 950 Town Harbor Road
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construefion located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
4)Budder s License No. / //~ Plumber's License No.
,~ //1'1
Electrician's License No. /'~//~'~ Other Trade's License No.
Signature of Applicant
3-06-07
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) Tax Map: 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:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Covcra¢c (Aoach 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:
13) Securitw:
a)
b)
Bodily injury mid property damage: $300,000/$500,000 Bodily Ir[jury, and $50,000 proper~y damage.
Surety Bond or Certified Check provided in the total mnount
of $
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 1.£ = $10.00 -
~.~ @ S0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional If. ~ .30
646 Ft of Trench
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.f.~$0.50 $
Additional
No.
Additional
Utility Repair Excavations @ $I0.00 $
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
TOWN J;hP"'S~UTHOLD, NEW/flfORK
Peter W. Harris
Received by the Town Clerk ~/]~/07 <~/~/1~' ~. ISate
Permit Issued ~ J]~/l~"] DatePer,nit No. q ~(5'~
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:
I lighway Department
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
4th
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 lmproper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
F]LE No.978 03/06 '07 08:32 ID: FAX: PRGE 2/ 2
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
OPENING
W,OJPA
NO,
REQUESTED
BY
APPROVED
FOREMAN
DEPARTMENT
GAS CONSTR, MAINT.& SERVICES
DATE OF
OPENING
DIVISION
DATE
SKETCH
IbS-/7
N