HomeMy WebLinkAbout360 Riley AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/17/07
* * * RECEIPT * * *
Receipt~: 786
Transaction(s):
1 1
Permits
Reference Subtotal
485 $170.00
Check~: 786
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 485
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEIVED
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl007114Il
Souih~td T~,v:n Clerk
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) 360 Riley Avenue Mattituck Owner of Premises Address
3) Riley Avenue ~4x4' bellhole S/s Riley Avenue approx. 400' e/o Bay Avenue to install a gas
service to #360 Riley Avenue
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.
X
Signature of Applicant
1-10-07
Date
5) ~) 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) At~ach 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
7) Starting Date: Completion Date:
_, Lot
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 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)
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. _l/Service Connections excavations ~ $20.00 = $20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
O-lOO l.f. = $1o.oo -
1.£ @ SO.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi =
Additional 1£ ~ .30:
646 Ft of Trench
D. Excavations 5' in depth and over:
0-100 l.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 this application prior to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SU.~ENDENT OF HIGHWAYS
Peter W. Harri~
/
?
Date
Received by the Town Clerk
Permit Issued
Permit No.
N0t~: Pemit expires one (1) ye~ from Date of Issuance. No work to st~ without 48 hour notice to the Superintendent of Highways.
Pe~it must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC -BuiIding under Construction
WIP Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspector holding for final settlement ofcxcavation
RFR Ready to Repair
D-39 Page 3 of 3
~/~V-'/~ PER.,I~T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK
1510/2[07 9:12:~ AM
RILEY AVE
MAT'H'I'd CK
T100?11411
VILLAGE O1~
C~.0S$ ~'~REET: BAY AVE
SUF~AC~:
3~0
4' x 4' Ben Ho~e