HomeMy WebLinkAbout145 Fleetwood RdTOWN OF SOUTHOLD
HIGH%VAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00671264
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. - HICKSVII.I~I~_ NY 11801
Name of Applicant Address
2) 145 Fleetwood Road, Cutchogue Name of Owner of Premises
Address
3) Fleetwood Road - bellhole on the n/s 155' e/o Fleet Neck Road to install a gas service to
#145 Fleedwood Rd.
4)
4)Builder's License No.
Electrician's License No.
5)
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.
Plumber's License No.
X
Other Trade's License No.
Signature of Applicant
09-5-06
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 Rcpiaccment .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
Completion Date
11) Remarks:
W.O. #T100660593
12) Insurance Coverage (Attach Copy)
a) lnsumnce 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
nfs
Maintenance Bonded provided: 2 years or 3 years
14) Fees for anvlications 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 I.f. = $10.00 -
~.£ @ S0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.£ @ $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 Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk C~ [ t'] I ~(.~
Permit Issued C~! ~>/~)c Date Permit No. q(..at
SUPE~NT OF HIGHW,~Y/~
Date
Note: Permit expires one (l) year from Date oflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39
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Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~
4t~
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- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~11~' i~RMIT. APPLICATI(:~ SKETCH
~r~ ._~,__ GAS SERVICE
~ NYS ~ SUFFOLK
COUNTY [~-
LOCATION
TOWN
MAP ( 0
CROSS STREET_
WORK ORDER
SKETCH
N
TOTRL P, 02