HomeMy WebLinkAboutWestwood LnPermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100682244
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 Sonthold, 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 Tyne
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant
2) Westwood lane & Sound Drive
3)
4)
4) Builder's License No.
Electrician's License No.
Address
Name of Owner of Premises
Westwood Lane - 590' trench in the w/s grass area & 4 missle shots
Sound Drive - 156' trench in the s/s grass area & 4 missle shots
Install a gas main & 6 services
Work Description and Location (Street Number, Hamlet, Cross Stree0
(a) ls construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
Plumber's License No.
No X
~)
Address
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:
b) At/ach 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 Towr. Clerk.
Completion Date
Other Trade's License No.
Signature of Applic~t~
t0/t3/06
Date
a) At~ach 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.
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)
Sure~y Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: 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:
0-100 1.f. = $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional lf~ .30 = 746 fl. of trench ~ .30
$223.80
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 = $
Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $393.80
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 [ O - ~ .-~.
Date
Permitlssued ]O-~l.O-O0 PermitNo.
SUPERINTENDENT OF HIGHWAYS
Peter W~ HarCi~s
l~ate -c-
Note: 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
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB -lmpmper 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- Inspector holding forfinalsettlemantofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ KEYSPAN
'~ ~REQUEST FOR STREET OPENING PERM~
~ NASSAU ~ SUFFOLK r---] ~ /~ ~ ~
PERMIT J ' · MIS JOB~~ DATE .
,o. ~.~l. llm~J i,o. ~l,~..~./I /~I~1~
REASON FOR ~ _ ; ~
. DATE OF
, _~ ~ ~ DEPARTMENT )1- ~
I~/~ A, ~+ ~0~ ~GASCONSTR. MAINT.&SERVICES ~ ~ ,
. ~, ~'~
',~~.~~ ~. '
A
0CT-05-2006 07:52 P.03
N
KEYSPAN GAS CONSTR 631 950 5136
TOTAL P,O5
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/20/06
* * * RECEIPT * * *
Receipt: 7404
Transaction(s):
1 1
Permits
Reference Subtotal
470 $393.80
Check#: 7404
Total Paid: $393.80
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 470