HomeMy WebLinkAbout6000 Wickham AveDate: 12/08/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt~: 7697
Transaction(s):
1 1
Permits
Reference Subtotal
480 $170,00
Check#:7697
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 480
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£#TI00701450
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 oftbe
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 6000Wickham Avenue, Mattituck Owner of Premises Address
4)
3) Wickham Avenue, 4'x4' bellhole on the E/s of grass area, approx. 400' s/w/o Mill Lane to
install a gas service to #6000 Wickham Avenue
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.
Electrician's License No.
Plumber's License No.
Other Trade's License No.
Signature of Applieant
12-1-06
Date
5) 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) W~rkc~veredbythisapp~icati~nmayn~tc~mmencebef~reissuance~faHighwayExcavati~nPermit
by the Town Clerk.
6) Tax Map: Section ., Block
7) Starting Date: Completion Date:
S) 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:
_, Lot
Comoletion Date
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy It
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
13) Securit-/:
a)
h)
Bodily injury and prope~y damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Sure~y Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or _ 3 years
14) Fees for annlications and ~ermits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 1.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 aitached 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.
Received by the Town Clerk 4/t- O(3- O ~
Date
Permit Issued ~- ~ - O (" Permit No.
SUPERINTENDENT OF HIGHWAYS
Peter W. Harris
Date
Note: Permit expires one (1) year from Date oflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
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
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- Inspectorholdingforfinalsettlementofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
KEYSPAN GAS CONSTR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO.
LOCATION
REASON FOR
.OPENING
W.OJPA
NO.
REQUESTED
BY
F~NASSA"cou.T~ []oO..TYSU"°LK []
FOREMAN DATE OF
DEPARTMENT ~ DIVISION
GAS CONSTR. MAINT. & SERVICES