HomeMy WebLinkAbout765 Westview DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/27/07
* * * RECEIPT * * *
Receipt~: 8124
Transaction(s):
1 1
Permits
Reference Subtotal
489 $248.70
Checldt: 8124
Total Paid: $248.70
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 489
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£#TI00723046
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 of the
job site.
Print or Type
l) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) Westview Drive, Mattituck
Name of Owner of Premises
Address
4)
4) Builder's License No.
Electrician's License No.
$)
Westvier Drive- 2- bellholes and a 150' trench trench in the pavement~ S/s approx. 338' s/o
Brpwer Road to install a gas main and service (~765 Westview Dr.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*lf yes, other Town permits may be required.
No X
Plumber's License No.
v sig~at-u reef Applicant ! /
02/20//07
Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
ll) Remarks:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
by the Town Clerk.
6) Tax Map: Section .,Block
7) Starting Date: Completion Date:
8) Work Schedule:
Completion Date
Lot
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
D-39
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 thc 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. /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$2O.0O
(plus $30.00trench ~e
And .30 ea. foot bom 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 1.£ - $10.00 -
1.£ ~ SO. lO-
Additional
C. Excavations I8" in depth to 5' in depth:
0-100 l.f. -
Additional lf~ .30 = 746 1~ of trench ~ .30
D. Excavations 5' in depth and over:
0-100 I.£ - $50.00
1.£ @$0.50 $
Additional
NO.
Additional
Utility Repair Excavations ¢3 $10.00 = $
Repairs same service a~ $5.00 = $
Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST -- $248.70
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
TOWNJ31~SOUTHOLD, NEW/YORK
! Peter W. llarris
Received by the lown Clerk 7 D,~
Permit Issued ~t~/~'jO ? Date Permit No.
Note: Permit expires onc (1) year from Dateoflssuance. Nowork tostart without48 hournoticetotheSuperintendentofHighways.
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
1at
2~d
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
WIP Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS Inspector holding for final settlement of excavation
RFR Ready to Repair
D-39 Page 3 of 3
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