HomeMy WebLinkAbout1555 Village LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/10~06
* * * RECEIPT * * *
Receipt~: 7365
Transaction(.~):
1 1
Permits
Reference Subtotal
469 $170.00
Check~: 7365
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 469
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#T100683404
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) 1555 Village Lane, Orient
Name of Owner of Premises Address
3) Village Lane - bellhole on the e/s of Village Lane 235' n/o Fletcher St to install a new Rna
service to #1555 Village Lane
4)Builder's License No.
Electrician's License No.
6) Tax Map: Section
7) Starting 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:
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No.
Signatu Fe-of Jk:[~p~ca n t
10-4-06
Date
5) a) Attachpl~tplansh~wingl~cati~n~fpr~p~sedexcavati~nandrelati~nshipt~adj~iningpremises~r
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 appllcation may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
., Block , Lot
Completion Date:
Completion Date
W.O. #T100683404
12) Insurance Coveraae (Attach Copy)
a) Insur~mce 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) Secufily:
a)
Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and nermits: Basic Application Fee
Al. _l~/Service Connections excavations ~ $20.00 = $20.00
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10 =
_Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. --
Additional lf. ~ .30 =
D. 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 -- $170.00
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 /'/_~ -/~9 -O ~,
Date ~:~,~
Permit Issued fO -/O -~7~; Permit No.
SUPERINTENDENT OF HIGHWAYS
TON sOUrHOLr ,
Peter W. Harris
Date
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
1st
2~
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB -lmpmper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to me~sure (due to backfilling)
BUC - Building under Construction
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SI~TCH
DATE~
LOCATION~
TOWN:
WORK ORDER:
10/5/~00~ 9:01:37 AM
1555 VILLAGE LN
OP-.IENT
T106~83404
VILLAGE OF
(lOSS STI~ET: FLETCH]~. ST
SURFAC~
House NO,
1555
235'
4' x 4' Bell Hole
.I
VILLAGE LN