HomeMy WebLinkAbout575 Ackerly Pond RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/09/06
* * * RECEIPT * * *
Receipt~: 7507
Transaction(s):
1 1
Permits
Reference Subtotal
475 $170.00
Check~: 7507
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 475
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEI~
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR_ Sou~io[J~,- -.-
Ref.#T100691717
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. - HICKSVII,I,I~ NY 11801
Name of Applicant Address
2) 575 Ackerly Pond Road, Southold
Name of Owner of Premises Address
3) Ackerl¥ Pond Road - bellhole at the S/s approx. 246' w/o Lower Rd, to install a gas
service
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.
X
Electrician's License No.
Other Trade's License No.
Signature of Applicant
10-31-o6
Date
5) a) Atta~hp~~tp~ansh~wing~~~ati~n~fpr~p~sedex~avati~nandre~ati~nshipt~adj~iningpremises~r
publle 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:
__, Lot
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 (At~ach Copy)
FILE No.164 11/06 '06 10:54
FAX: PAGE 3/
Surety Bond ar Certified Check provided i~ lh~ mlal amount
ors
b) MaLn~nan¢c Bonded provided: 2 yeat~ or 3 y~at~
14) c~ o ~ ' a: Basic
Al. _1.~/$r~rvicc Connections excavations ~ $20,00 =
A2. /Additiona] Excavnfions same ~rvi~ @ $ I 0.00 ~-
No.
$1~0.o0
B. Excavations la*' in d~pah or less:
0-100 Iff. = $10.00 -
l-f. ® $040 =
646 Fl of T~'cnch
Utility R~air Excavations (~ S I 0.00 ~- $.
No,
. Regai~ same ~,rvice ~ $$.00 = $_
Additional
F. Notice to public mJlities prnofmu.q be provided and attach~l to this ~plic~tion prior to issuance of
l~mit,
TO AL COST = I ?0.00
Aull~ni~llh~ is hc~by gramM m ~ Towrl Cknk ofl~e Town of So~thold to ~ a I"~hway Excavatio~ Pcrmi~ m:
IO~YSPAN ENERGY DELIVgRy in a~:ordanc, e w~ this applioatio~.
4
Co~v D/su'ibu~/on:
Highway Deparancnt
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
nth
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- BuildingunderConstruction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS - Inspector holding for final setilement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT
NOi
LOCATION
REASON FOR
W.OJPA
NO.
REQUESTED
BY
APPROVED
MIS JOB / DATE
NO. "-MOO [~]1 7/7
FOREMAN
DEPARTMENT
GAS CONSTR, MA NT. & SERVICES
DATE OF
DIVISION
DATE
SKETCH
N