HomeMy WebLinkAbout6495 Peconic Bay BlvdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/2,9/06
* * * RECEIPT * * *
Receipt~: 7301
Transaction(s):
1 1
Permits
Reference Subtotal
467 $170.00
Check~: 7301
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 467
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
· RECEIVED (j~
Souij~,jcl T~,~=n Clerk
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00677822
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) 6495 Peconic Bay Blvd, Laurel Name of Owner of Premises Address
3) Peconic Bay Blvd. - bellhole on the N/s in the grass area~ approximately 1122' w/o Bray
Avenue to reconnect atas service to 06495 Peconic Bay Blvd.
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.
X
Electrician's License No.
Other Trade's License No.
Signature of Applicant
09-25-06
Date
5)
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
publle 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 , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
I1) Remarks:
W.O. #T100660593
12) Insurance Coverage (At~ach 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)
b)
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
orS
Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoolications and pemaits: 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.~ @ $O. lO =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .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.
SUPERINTENDENT OF HIGHWAYS
To ¢o .o TwYo
- Peter ~.~s
Date
Received by the Town Clerk
Date
Not~: P~itexpiresone(l)ye~omDateoflssu~ee. Noworktos~without48hournoticeto~eSu~rintendentofHi~ways.
Pe~it must be available for ins~ction.
D-39 Page 2 of 3
Cot~v Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
ist
2r~
3rd
Findings(use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB -lmproper 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- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN
FOR STREET OPENING PERMIT
~ COUNTY COUNTY
PERMIT
MIS JOB~.?~]
NO, NO, 7/~o~777zz DATE
REASON FOR
W,O,/PANO, FOEEMAN ' DATE OF
BY J GAS CONSTR, MAINT. & SERVICES
APPROVED DATE
SKETCH
/ ~C '
~b
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TOTAL P.02