HomeMy WebLinkAbout445 Marlene LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/27/06
*** RECEIPT***
Receipt#: 7471
Transaction(s):
1
Permits
Reference Subtotal
471a $223.80
Check#: 7471
Total Paid: $223.80
Soett~(~c] Tc, wn Clerk
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 471a
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/25/06
* * * RECEIPT * * *
Receipt#: 7449
Transaction(s):
1 1
Permits
Reference Subtotal
471 $170,00
Check~: 7449
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 471
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGI-I~VAY EXCAVATION AND REPAIR
Re£#TI00687231
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) Westwood lane & Sound Drive
Name of Owner of Premises
Address
3) Marlene Lane - bellhole on the e/s paved area 511' s/o Main Road to install a gas service to #445
4)
Marlene La.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
No X
4) Builder's License No.
Electrician's License No.
s)
Plumber's License No.
Other Trade's License No.
Signature of Applicant
10/23/06
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
7) Starting Date:
8) Work Schedule:
_, Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
D-39 Page 1 of 3
T100612250
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 amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for armlications and oermits: Basic Application Fee
Al. /Service Connections excavations ~ $20.00 =
$150.00
$20.00
/Additional Excavations same service ~ $10.00 =
No.
Excavations 18" in depth or less:
0-1oo 1.£ = $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If~ .30: 746 1~ of tranch ~ .30
Excavations 5' in depth and over:
0-100 l.f. - $50.00
l.f. ~ $0.50 - $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
F. Notice to public utilities proof must be
permit.
$223.80
TOTAL COST -- $393.80
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Date
Permit Issued fro ~ .,~ ~'tg~b, Permit No.
SUPERINTENDENT OF HIGHWAYS
TOWNA~UTHOLD, NE~ YORK
Peter ¢/~ Harris
Date
Note: Pannit 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
2n~
4th
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- lnspectorholding for final settlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
OCT-~2-2~o6
KEYSPAN GAS CONSTR
KEYSPAN
REQUESTFORSTREETOPENING PERMIT
631 ?58 5136 F'.02
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
n---]' STATE ~ NASSAU SUFFOLK
COUNTY ~ COUNTY
MIS
NO. JOS,~.~',~ ~ 87~-~ /
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT, & SERVICES
DATEOF
OPENING
DIVISION
DATE
SKETCH
N