HomeMy WebLinkAbout165 Walnut StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/19/07
* * * RECEIPT * * *
Receipt"8: 7894
Transaction(s):
1 1
Permits
Reference Subtotal
486 $170.00
Check~: 7894
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 486
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEIV2D
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
So~t{~[d Tcv,'n Cledc
Re£#T100711778
APPLICATION IS HEREBY made to the Superintendent of ltighways 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) 165 Walnu(Street Mattituck Owner of Premises
Address
3) Walnut Street 4'x4' bellhole W/s Walnut Street approx. 145' n/o Oak Street to install a
gas service to #165 Walnut Street
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.
4)Builder's License No. Plumber's License No.
Electrician's License No.
Other Trade's License No.
signature of Apptican[
1-1147
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 appllcation may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
., Lot
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 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:
13) Security:
a)
b)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond . or Certified Check provided in the total amount
orS
Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.00
B. Excavations 18" in depth or less:
0-100 1.£ = $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
O-lOO L£ = $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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KE¥SPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ] - / % O 7
Date
Permit Issued t/-/~' - r_.2 7 Permit No.
SUPERINTENDENT OF HIGHWAYS
TOWJ~WNSOUTHOLD, NF/,,W YORK
Peter W. Harris
Date
Not__e: Pemfit expires one (1) year from Date of Issuance. No work to start withou148 hour notice to the Superintendent of Highways.
Permit must be available for inspection
D-39
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
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
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
Q~UE KEYSPAN
RE ST FOR STREET OPENING PERMIT
PERMIT
NO.
LOCATION
[-'~STATE ~ NASSAU SUFFOLK
COUNTY ~ COUNTY
REASON FOR
OPENING
W,OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
MIS JOB
NO,
FOREMAN DATE OF
OPEN NG
DEPARTMENT DIVISION
GAS CONSTR. MAINT, & SERVICES
DATE
TOTAL P. 03