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HomeMy WebLinkAbout20 Harbor River RdTown Of Southold P.O Box 1179 Southold, NY 11971 Date: 12/01/06 * * * RECEIPT * * * Receipt~: 7582 Transaction(s): 1 1 Permits Reference Subtotal 478 $170.00 Check~:7582 Total Paid: $170.00 Name: Keyspan, Energy - Gas Cont Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 478 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£#T100687986 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) 20 Harbor River Road, Orient Addrcss Name of Owner of Premises Address 3) Harbor River Road~ hellhole on the S/s of Skippers Lane at the intersection of Harbor River Road 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. Electrician's License No. Plumber's License No. Other Trade's License No. Signature-of Applicant [ / 10-31~6 Date 5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r 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 7) Starting Date: Completion 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: $ !1) Remarks: , Lot Completion Date 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 mount of $ b) Maintenance Bonded provided: 2 years or 3 years 14) Fees for applications and permits: Basic Application Fee Al. 1 /Service Connections excavations ~ $20.00 = $150.00 $20.00 A2. /Additional Excavations same service ~ $10.00 = No. B. Excavations 18" in depth or less: 0-1001.f. $10.00- l.f. @ S0.10 = 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 l.f. = $50.00 L~ @ $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 -- $170.00 Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to: KEYSPAN ENERGY DELIVERY in accordance with this application. Received by the Town Clerk Date Permit Issued ]¢~ - /- 06' Permit No. SUPERINTENDENT OF HIGHWAYS TO~f~I'I~OUTHOLD, NEW Y~ORK Peter W. Harris Date Not__e: Permit expires one (1) year f~om Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways. Permit must be available for inspection. D-39 Page 2 of 3 Copy Distribution: Highway Department Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date 2~a 3rd 4th Findings (use code) Applicant Notified (To Permit Clerk) REMARKS CODE IB - Improper barricades IL - Improper lights ST - Sunken trench or excavation UTM - Unable to measure (due to backfilling) BUC - Building under Constraction WIP - Work in Progress DB - Improper backfill (too high) (not sufficient) HFS Inspector holding for final settlement of excavation RFR Ready to Repair D-39 Page 3 of 3 PERMIT APPLICATION SI~TCH DATE; LOCATION: T OWN: WORK (~[DER: 11/~f2{116 3:04:42 PM 2] HARBOR RIVER RD ORIENT T100g$?~6 VILLAGE OF · fREET: HARBOR I~VER Macad~a Ro~l © House NO. '~0 4' x 4' Bell Hole SKIPPEI~ LN FILE No.279 11/21 '06 16:05 File No. TOWN OF SOUTHOLD HIGIIWAY DEPARTMENT Peeonic, New York ll~8 (631) ~PLICA~ON~E~ ~R ~AY EXCAVATION P~GE 1/ Work Description and Location (Street Number. Hamle~ Cross Street) (a) Is conm'uc~ton laes~ed wlthia 7S f~ ~tM~t w~and~. *Yes No · Ifye~. ot~er Town permits may be 4)Builder's License No. E4ectrkhn'a License No, S) Plumber's lJceuse N~ Other Trade's l~ense No. $1gnatu~?f A~pli~ant a) A~ pl°t P~n' ~°~ ~on of P~ ~on and ~fio~hip ~ a~olnin~ p~m~ or publ~ ~ or ~ ~d ~ng a d~i~ dne~pff~n of hyout of ~v~on. b) A~h all ~ n~ ~m~ Hd [~enm for ~h pmj~ c) Work t~ by ~ a~h~on m~ not commence ~ore ~u~ ora ~hway E~aflon ~mJt by ~e To~ ~e~ 6) T~ut Map: Stnr~ng 8) Work Schedule: , B~ock , Lot Completion Dat~: F~ili~y/nstslla~ion ............................................................... Backfill & Compa~l~m ......................................................... Payment RCl~heement ......................................................... 9) Under which authority h thc application made; lO) V~timoted CostofProlu~dWork: S 11) Remarks: copy) FILE No.279 11/21 '06 16:06 FAX: PRGE provid~ in U~c tmal amount $I~0.00 ti, Ex~ava~ons 18" in d~oe~ or less; O-lO0 1.£ ' $10,00 - .. l~.cava~ioas 18" i~ dep~ ~o {' ia dep~: 0-1001.£ - Adcli~ional I~. @ .30 -~ F..xcava~ons $, in &:p~ and ova: O-lO0 Lf. = $.~0.00 Utility lh,l~ir l~cav~iom @ S10,0o = $ Addifioaa{ R~pairs ~me mcrvi,~ @ S$.0o ~ ~ Notice to public mil/uez proof mu~ be provided md roached ~o ~i~ ~p91ic~io~ prior to iss~eace of Au~'~/,., im ben, by {r~cd ~a'~ ?aw~ Ck~k of~ Tow~ ofSoud~d ~ ~_._ a Highv~y EXCav~io~ ~ ~¥SPAN ~,NE RG'Y DELFV~Ry. M ~ wi~ this mpplic~cm. Rccoiv~ by ~hc Tow~ CI~ Permit Issued SUPEKINTENDENT OF HIOH~AYS -- -- Peter W. Ha.~is 2/ 3 FI.LE No.279 llx~l '06 16:06 Towa Clerk FAX: PAGE 3/ 3 code) Applicant Notified (To Pemk Cltak) D-3g