HomeMy WebLinkAbout840 Marlene LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/09/06
* * * RECEIPT * * *
Receipt"8: 7508
Transaction(s):
1 1
Permits
Reference Subtotal
474 $170.00
Check~: 7508
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 474
Permit No. l~
File No. ~
RECEIVED
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane r ~.
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION ANl~i~,Jl~Tb¥;tl Clerk
ReL#TI00692005
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 Addrt~s
2) 840 Marlene Lane, Mattituck
Name of Owner of Premises Address
3)
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.
Marlene Lane - bellhole on the W/s (grass area~ approx. 959' s/o Main Road, to reinstall
s)
Electrician's License No.
X
Other Trade's License No.
Signature of Applicant
10-31-06
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) ARach nil 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 Cleric
6) Tax Map: Section ., Block , Lot
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:
12) Insurance Coverage (A~tach Copy)
Completion Date
. FILE N%164 11/06 '06 10:55 ID: F~X: PI~GE 4/ 4
/Addi~ual Excavations same son, ice @ SlO.O0:
No.
B. Ex~va~ions 18" in dcpth of
0-I00 Lf. = $10.00 -
..... l.f. ~ So.~o ~
C. Excavu~/mls Ir/n depth m ~' in d~pth:
0-100 I.f, =
AddiUonal Lt$ .30 =
D. Excava~/o~ 5'/n depth and over:
o- I00 I.£ = .~0.0o
iz. @ So. so = $.
Addifiona/
646 Ft of Trench
No,
Additional
__ Utility Repair Excavations (~ $10.00 - $
Repairs same ~ervice ~ S$.00 = $
Notice to public ulilitie~ proof must Ix: provided and almache, d lo this appHca[ion prior to issuaacc of
~170.00
Autho~on is he.by ~lm~ed to ~¢ Town Cleric of~h~ Town of Southold to ~ a Highway Excavatioo Pr. trait
K~YSPAN ENErGy DEI,IV~y in acc~'dfln~e with Ihi~ appllca/io~_
Receivod by thc Town Clerk
SUPERINTENDENT OF HIGHWAYS
Co~,v Distribution:
Highway
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
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 Construction
WIP Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspectorholdingforfinalse[tlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSP~N G~S CONSTR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W,O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
~-]STATE
DATE
FO~REMAN
IDATE OF
OPENING
DEPARTMENT DIVISION
GAS CONSTR. MAINT. & SERVICES
DATE
/..P /,~ l o l- b 7- ,/