HomeMy WebLinkAbout2000 Sound DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/25/07
* * * RECEIPT * * *
Receipt'8: 7925
Transaction(s):
1 1
Permits
Reference Subtotal
487 $229.70
Check~: 7925
Total Paid: $229.70
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 487
Permit No.
File No.
TOWN OF SOUTHOLD
H1GHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100686293 $o:,? '! T~ ," ~{
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
2) Sound Drive, Greenport
Address
Name of Owner of Premises
Address
3)
Sound Drive - bellhole and a 200' trench in the pavement, S/s approx. 230' w/o Inlet Pond Lane
to install a gas main and service
4) Work Description and Location (Street Number, Hamlet, Cross Stree0
(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
01/19//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 ora Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section ., Block , Lot
7) Starting Date:
8) Work Schedule:
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:
Completion Date
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 the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 properly damage.
13) SecuriW:
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
$20.00
(plus $30.00 trench fee
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
1.£ @ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. -
Additional lf~ .30 746 fl of trench ~ .30
D. Excavations 5' in depth and over:
0-100 l.fi $50.00
1.£ @ $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 = $229.70
Authorization is hereby gr ranted 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 t//~'~"~
Date
SUPERINT~I~)ENT OF HIGHWAYS
Peter W. Harris
Date
Permit No. q~ 7
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
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 Improper backfill (too high) (not sufficient)
HFS- lnspectorholdingfor final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN Me
REQUEST FOR STREET OPENING PER
C-~ ~ NASSAU F-~ SUFFOLK
FC-~n,.4 I I STATE ~ COUNTY L~ COUNTY ~L~
PERMIT ' MIS JOB ~ ~DATE
LOCATION ~ ~
REASON FOR ~ ~ ~ ~
~ ~ ~ ~ ~ ~;,. IDATEOF
/u'L~'~ ' ~" ~ OPENING
REQUESTED~ DEPARTMENT DIViS ON
BY ~ GAS CONSTR. MAINT. & SERVICES
l
TOTRL ?. 04