HomeMy WebLinkAbout250 6th StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/10/06
* * * RECEIPT * * *
Receipt'8: 7364
Transaction(s):
1 1
Permits
Reference Subtotal
468 $170.00
Check#: 7364
Total Paid: $170,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 468
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
Re£#T100683507
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. - H1CKSVILLE~ NY 11801
Name of Applicant Address
2) 250 6th St Name of Owner of Premises
3) 6th St - bellhole on the n/s of 6th Street 270' w/o Ra~.Avenue to install a
#250 6Ch Street
Address
new gas service to
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.
Electrician's License No.
5)
Other Trade's License No.
Signature of Al~li~'~
10-4~6
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 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 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
W.O. #T100683507
12) Insurance Coveraae (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:
13) Security:
a)
h)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
nfS
Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: 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.fi =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.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 /'O -/,0-dY(,,
Date
Permit Issued /19 -/'0 - t9~ Permit No. L-/,/~:~OC'""'
SUPERINTENDENT OF HIGHWAYS
/0 -/c/--c,~
Date
Note: Permitexpiresone(l)year fromDateofIssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39
Page2of3
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2,~
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
IL - Improper lfghts
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 for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SlClg, TCH
DAT~:
LOCATION:
TOWN~
WORK
1055f'~06 8:55:09 AM
250 6TH ~T
MAT1]TUCK
T10{~83507
V]I,LAGE OF
CROSS STREET.* BAY AVE
~L~KFA(~t
Mac=hmRo~i
I'Io~ Nil
~0
~ 270'
?
4' x 4' Bell Hob
6TH ST