HomeMy WebLinkAbout885A Wickham AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/05/07
* * * RECEIPT * * *
Receipt#: 8181
Transaction(s):
I 1
Permits
Reference Subtotal
490 $170.00
Check-8:8181
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 490
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
Reft#TI00726873
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
1) KEYSPAN ENERGY -GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 885A Wickham Avenue Mattituck Name of Owner of Premises Address
3) Wickham Avenue- bellhole on W/s Wickham Ave. 194' s/o Rt 48 to install a gas service
to #885A Wickham Ave.
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.
Plumber's License No.
Other Trade's License No.
Signatore of Applicant
3-01-07
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.
¢) Work covered by this application may not commence before issuance ofa ltighwny Excavation Permit
4)Builder's License No.
Electrician's License No.
by the Town Clerk.
6) Tax Map: Section ,Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facilil~ Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
I I) Remarks:
., Lot
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 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 pemlits: Basic Application Fee
Al. 1 /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. I0 =
Additional
Excavations lg" 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
l.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 th is 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
TO¥~(~SOUTHOLD~ ~i'l~W YORK
~ct effW. Harris
Received by the Town Clerk ,~/,5/~
Permit lssued ~ _ ~/_D~/,) ~ Date Permit No.
Note: Permit expires one (1) year from Date of Issuance No work to start without 48 hottr 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
1 st
2nd
3rd
4th
Findings (use code)
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
WlP - Work in Progress
DB - improper backfill (too high) (not sufficient)
HFS- lnspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION~SKETCH
GAS LEAK REPAIR
~ NYS F~ SUFFOLK
COUNTY
TOWN /~ATTt
AVE
MAP
CROSS STREET
WORK ORDER
SKETCH
N
TOTAL P. 02