HomeMy WebLinkAbout2006 Gull Pond LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/15/06
* * * RECEIPT * * *
Receipt~: 7592
Transaction(s):
1 1
Permits
Reference Subtotal
476 $170.00
Check'#: 7592
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 476
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
ReL#TI00694493
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) 2006 Gull Pond Lane, Greenport- Owner of Premises Address
3) Gull Pond Lane~ bellhole in the grass area ~ end of road~ approx. 1~950' s/o Main Road
to install a gas service (new house)
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*lf 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
s)
Signature of Applicant
11-8-06
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 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:
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: $
11) Remarks:
, Lot
Completion Date
12) Insurance Coverage (At~ach 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) SecuriP/:
a)
Surety Bond _ or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoolications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$2o.oo
A2.. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.£. = $10.00 -
l.f. ~ $0. I0:
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi =
Additional If. ~ .30 =
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 atlached to this application prior to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to lhe 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~- 0 (~
Date
Permit Issued //-/,5- - 0 ~ Permit No.
~LNDENT OF HIGHWAYS
Peter W. Ht[rris
Date
Not__e: 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
2nd
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- Inspectorholdingforfinalsettlementofexcavation
RFR Ready to Repair
D~39 Page 3 of 3
KEYSPAN GAS CONSTR E31
KEYSPAN
~UEST FOR STREET OPENING PERM?I~
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
REQUESTED
EY
APPROVED
[] STATE ~ NASSAU SUFFOLK
COUN,Y [] COUNTY
m~-~d & ~ b?P~ Iq~'~ '~/~ /n~'.~ ~ ?7
FOREMAN DATE OF
DEPARTMENT DIVISION
[ GAS CONSTR. MAiNT. & SERVICES
I DATE
SKETCH
N
U
TOTAL F'. 85