HomeMy WebLinkAbout2055 Bay AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/09/07
* * * RECEIPT * * *
Transaction(s):
1 1
Permits
Reference Subtotal
484 $170.00
Check~: 7874
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 484
05/01 '07 MON 11:37 FAX 631 765 6145
FIL~ N0~474 01/08 '07 09:~8
$OUTHOLD TO~ CLERK
P~mit
File
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic I~ne
Peconlc, New York 11958
(631) '~65-3~ 40
APPLIC~TION/I~FJ~XT FO]~ HIGHWAY EXCAVATION AND REP~Vu
1) KEYSPAN ENERGY- GA~i~ONSTI~. DF~F. - )75 E- OLD CO~V ~.- MC~VII.I_~ ~ ~ 1~01
2) 20~ ~y Avenue Ms~ituck Owner of ~m~ Add~
3) ~av Avenue~ 4'x4' hellhole 1.~-0. #'20S$ BAY Avenue, al?p_~M~ 73S' ~/a ~nrtiev Cour? fn
r~air a ~os servf~e to ~'20SS ]BaY Av~ue
4)
4)Rullder*a License No.
£1ectria~ln'e License ~o.
Work DescrfptiQn and Lo~Kion (Street Numl~r, Hamlet, Cress Street)
(m) b eo~/r, ctJee Io~:l~.'dwi~ifl 7S t~tof~lai wetlands** *y~ No~
Plumber's Lic~ No.
~iffnature of Applicant/
1.8.~
Date
a) A~h plot plan slewing Io~at~n M prop~ ex~vaflo~ and relafio~hfp to a~ainin~ p~m~ or
pDM~ sWe~ or Irca~ and gi~og a d~il~ d~cri~oe ef ~your ofcx~vafion.
b) A~ch all oth~ n~ ~rmj~ ~d lite~ for ~is
t) Work cove~ ~ ~b ~pplicafion may not commcn~ b~orm i~uanct of a ~h~y E;cavafian pc~it
5) TnZ M~ap: S~-'dou , Block
7) SmrtlnR Date: ~ampleSon
8) Work Schedule'-
P~ase ~nmt*letion
KscavelJ~ .........................................................................
~a~nW lnRnlta~n
B~ct~ll & ~nnlm~l~on ......................................................... --
Under which authority b t~e epplJee§en made:
Estimated Cost of Proposal Work: $
11) Remurks:
002
5
08/01 '07 M0N 11:38 FAX 631 765 6145
FILE No,474 0t/08 '07 09:29
SOUTHOLD TOWN CLERK
-*-*-~ Hlghwa,~r Depl;
OO3
PaCE 3/ 5
Iii)
Sku~y Bond or Cectifi~l Chcr..~ provided in ~e toad amount
b) ~a~hl~snc~ BQ~:]~I provided; ~ yea~ or 3 years
14.) fo ' ' i '~:
Al. ~l~/~[viCe
$1~0.00
/Additia~ F,x~avagons s~me servia, ~ $ I 0.00 -
No.
B. Ex~vntions lg"in d,~pt~ or
o-i00 I.C ,, $I0.00 ~
. I.f- ~.SO. lO =
Addilional
__ UgHty Repair ~,xcavalio ns (~ $10.00 = $.
Repairs ~ scrvlc, e ~t $5.00 = S.~
Nog.cc lo publl~ u~it. ics proof mus~ be ptovidot and atav;hed m this application [nior to ss~ncc Of
pr. nmL
TOTAL COST = $170.00
Tow CI,~,~. of tl~ Tovm of ROlO'laM I~ iss~ ~ I.U~,, F. xcavai,~ Pco~it m:
D RI..Iv'K~y in a~lan~ v~ ~s ~pplicatiee.
OF HIGHWAYS
08/01 '07 M0N 11:38 FAX 631 765 6145
FIkE No,.474 0&OS 'O? 09:2@
soeraoLv TOW~ c~ .~___
Highway Dept
004
Apptir-~t
Town Clerk
AppUca~t N~Jfied
(To Petmi! Cled)
Page 3 of 3
08/01 '07 MON 11:38 FAX 631 765 614,5
?ILE Nq.474 01/0~ '07 ,gS':~9
SOUTHOLD TOWN_.CLERK
FAX:
-~-~-~ Hlghwa.v Dep~;
~005
PA~E ,~ S
09/01 '07 TIlE 15:31 FAX 631 765 6145 SOUTHOLD TOWN CLERK ~001
*** TX REPORT
TRANSMISSION OK
TX/RX NO
CONNECTION TEL
CONNECTION ID
ST. TI~E
USAGE T
PGS. SENT
RESULT
3172
915165454941
09/01 15:30
01'13
4
OK
08/ol '07 ~ON 11:37 F.l~l~ 631 755 $145
FIkE No_474 01/0~ '07 09:~ ID:
SOU~nOL~ TOW~
AI'P~LICATION~T FOR ltlGI-I~ y EI(CAVATION AW~ R_RlaAT~
1~£UT100'109913
4)
"i) B~qy.&?.enue~ 4'~' b~llhole l.~r-O. ~SS ~y Avenue apGr~ 73P ~o Ba~ey Cop~ ~fl
~air a ~ ~ to ~0~ ~v ~ven u e
Wo~ D~c~on and Loo~on ($tr~ ~um~r. ~l~ C~ Stsc0
Pla~ber'a Lic~ N~
· ~a~e of Appli~ntt '
a) Atl~ plot phm sho~ieg lacatien 6f prap~ ex.ration nM r~g0~Mp to adJaining p~ or
public sk~ or arca~ and ~g a d~il~
b) ~ all ~th~ n~ p~mi~ ~d li~ for ~ls ~j~
c) Work cova~ ~ ~ a~agop ~ay no~ comm~ce b~a~ issuanc~ nfa ~ghway g~ava~=n P~it
by the ~a~n
oo2
01/08 '07 09:28
ID:
FAX:
PAGE
1/ S
EnergY Delivery
w
Phone
Fax ~
RECEIVED
JAN, 8 2O07
SoutholdTowfl Clef[
474 01/05 '07 09:28 ID:
FAX:
Fermit No. l ('~~
File NO.
TOWN OF $OUTHOLD
H1GI-I~/AY DEPARTMENT
Peconi¢ Lane
Peconic, New York 11958
(631) 76~-31d0
APPLiCATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEB. KBY made la the Sup~rintendont of ~way~ 0fthe T~n of~uchdd for the in~nce of
au Ex~a~ finn Permit pu~a~ W ~ap~r ~ of th~ C~e of thc Toww Df ~utb~dw S~ffolk Co~nW, N~ York a nd other
a I~ble laws, ordinan~s or ~olldonJ for the exea~doa he. in d~ri~. The applicant agre~ to comply with all
n~licabl~ laws. ordinan~ cod~ and ~ul~doos, and to permil a~lb~i~ ins~eto~ to make nec~a~ inactions of thc
job
Print or Tvpe
I) ]CEYSPA~q ENERGY - GAS CONSTR. DEFT. - 175 E- OLD COUNTRY RD. - HICKSVILLE, NY 1 t801
2) 20SS Bey Avenue Mattituck Owner of Premises Address
3) ~q¥ Avenne. 4'T4' _*~_!!h~le ].F.O. #2055 ~1~¥ Avenne approx. 735' nip ~nrtley Court
renair a ~ semite to ~D~S Bay ~vepue
4) Work Description and Location (Street Number, ~ml~, Cro~ Street)
ti} b construction I~a~ within 7~ f~[ of fid~ wetlands-* *Yes No ~X
*If yes, other Town ~rmih may ~ ~quired,
4)Buitder's License No.
El~trician's License No.
Plomber's License No.
Kignaturn of Applicant/
Date
$) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a d~iailed description of layout of excavation.
b) AU~ch all other n~essary permits and licenses for this project.
c) Work covered by thb application may not commcn~ before issuance of a Highway E~cavati°n Permit
by the Town Cler~
6) Tax Map: S~on ~ Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Facility Ins~allldoo ..............................................
Backfill & Compaction .........................................................
pavement RepJacemcot. .............
9) Under which a~thori~ is ~e npplica~on made:
10) Estimat~ Cost of Pro~ Work: $.
Il) Remarks:
12) {nsumnCe Coverage (Atug:h Copy)
a} Insurance Company:
PAGE
2/ 5
?4 01/08 '07 09:29 ID: Fnx: PnGE 3/ 5
c) Su~ whether policy of ce~ific~ion on fik with the Highway Department: _
d) Coverage requirod cx~.,-nded to ~h¢ Town:
Bodily injury and properly damage: $300,000/$500,000 Bodily IRjury, and $50,000 property damage.
Security:
a) Surety Bond or Certified Check
nfs
b) Maiu~ce Bondex{ providcd: 2 years or
for annlication:~ and ~rmil~; ~On
Al. I /Stn'vice Connc~ions excava£ions
A2. /Add{tional Excavations same scrvi~
'No.
providr, d in the loud amo,nt
3 yca~S
$1~0.00
ExCavations 18" in depth or ]cs.s;
0-100 l.f. ~ $10.0~ -
Lf. @ $0.10 =
Additional
Exravations 18" in depth ~o 5' in depth;
0-100 I.f. '
Addit{onal If, ~ .30 ~
646 F~ of Trench
D, i~cavmions 5' in depth and owr:
o-10o 1.£ = s~o.oo
l.f. ~) SO. SO = $
Additional
B. . Ut lity Repair Excavations (~ $10.00 ~' S
NO.
Repairs sarn~ scrvic~ @ $5.00 = $.
Additional
F. Nnfic~ tn public utilities proof mus~ be pmvid~ ~d ~hed m ~ app{{~tian prior Zo }~ or
peril
TOTAL COST = $170,00
Au~horiz~ion is h~mby ~t~,:l lo ~ha Town Cl~k of ~h~ Town of $oulhold m issue a I-figh',vay Excavation Permit ~o:
KEY~PAN ~NE]~GY DELIVERY m accordmce wb ~is application.
SUP£R.{'NTE'N'D~NT OF HIGHWAYS
TOWN OF SOUTHOLD, NEW YORK
P~erW. Harris
Rcceivad by the Town Clerk
Date
Permit Issued Permit No.
Permit must b~ available for inspection.
Copy Diminution:
Highway Departmenl
,.474 01×09 '07 09:29 ID: Fa×: PA6E 4× 5
luspe, c~or
Town Cl~rk
iNSpeCTOR,5 RECORD
Inspection D~te
Finclin~s (use code)
Applica~ Notified
(To Permit Cle~)
CODE
lB - Improper barric~¢s
IL - ~proper li~bzs
ST - SLmic~n ~Xench or Cxcav~T. ion
~M- Un~l~tom~ure(duetobackfilliu~)
BUC - Buildin~ under ~ns~c~ion
WIP - Work in ~o~
DB - Improper bac~l] (~o hi~) (not
HFS- ~ectorho~dingfor~n~lse~l~cn~ofexcavafion
~R- ~ To Rcp~r
Page 3 of 3
LOCA~ ION:
! OWN~
BAY &V
T100'~973
PERMIT APPLICATION $~TCH
VILLAGE OF
CRO~i~i 5TR~T: 8~.~Y ~D
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~#T100709973
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 1 l$0t
Name of Applicant Address
2) 2055 Bay Avenue Mattituck Owner of Premises
Address
3) Bay Avenue, 4'x4' bellhole I.F.O. #2055 Bay Avenue approx. 735' n/o Bartle¥ Court to
repair a gas service to #2055 Bay Avenue
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(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.
Plumber's License No.
Electrician's License No. Other Trade's License No.
Signature of Applicant!
a) Attach plot plan showing location of proposed excavation and relationship to adjoining/p/rremises or
5) 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 l~ghway Excavation Permit
by the Town Clerk.
6) Tax Map: Section _,Block / ,Lot
7) Starting Date: Completion/J~e:
8) Work Schedule:
Phase //J Completion Date
Excavation ......................................................... ~ ............
Facility Installation ............................................ ./ .................
Backfill & Compaction ..................................... ,~. .................
Pavement Replacement ................................... ~'. ....................
9) Under which authority is the application mad/~
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:
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. I /Service Connections excavations ~ $20.00 =
$150.00
$20.oo
A2. /Additional Excavations same service ~ $10.00 -
No.
B. Excavations 18" in depth or less:
0-1001.f. $10.00-
l.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f.
Additional 1£ ~ .30
D. Excavations 5' in depth and over:
0-100 l.f. $50.00
I.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.
SUPERINTENDENT OF HIGHWAYS
TOWN OF SOUTHOLD, NEW YORK
Peter W. Harris
Date
Received by the Town Clerk
Date
Permit Issued Permit No.
Note: 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
l~t
2nd
4th
Findings(usecode)
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 lmpropcr backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DAYE:
LOCATION:
TOWN:
WORK C~iDER:
1/8.,~OOV 9:~:$1 AM
~055 B AY AV
MA'I~rIUCK
T100".~09~;r'/3
VILLAGE OF
CROSS ~"fREE~: BARTLEy KD
20~
?35
4' x 4' Bill Hole
BAY AV
*** TRANSMISSION REPORT
PRINT TIME 01/08 '07 09:30 ID:
TIMER:--:--
FILE START MODE
No. TIME
474 01/08 09:28 TX
ERROR PAGE=
LOCATION
916317656145
FAX:
U*****2AN 181 3
STORE TX/RX TOTAL CODE
PAGE PAGE TIME
5 5/ 0 01'37" OK
Ene Jy Delivery