HomeMy WebLinkAbout270 Bay AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/16/06
* * * RECEIPT * * *
Receipt: 7080
Transaction(s):
I 1
Permits
Reference Subtotal
459 $170.00
Check~: 7080
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 459
Permit No. _
File No.
TOWN OF SOUTHOLD
HIGI-I~VAY DEPARTMENT
Peconic Lane
Peconic, NewYork 11958
(6.31) 765-3140
APPLIC. · IONfPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100663236
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for thc 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 Tyne
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVII~I.E. NY 11801
Name of Applicant Address
270 Bay Avenue, East Marion Name of Owner of Premises Address
.3) Bay Avenue- bellhole on W/s approx. 265' s/o of Main Road to in~tnll a gas service to #270
4)
4)Builder's License No.
Electrician's License No.
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.
Other Trade's License No.
X
Signature of Applicant
08-10-06
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
public streets or areas, nnd giving a detailed description of layout of excavation.
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 Town Clerk.
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:
Completion Date
12) Insurance Coveraee (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 lnjury, and $50,000 property damage.
13) SecuriW:
a)
Surety Bond. or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and ~ermits: 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. = $1o.oo -
l.~ @ $o.10 =
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.
Received by thc Town Clerk
SUPERINTENDENT OF HIGHWAYS
I -~te '
Note: Permit expires one (l)yea~fi-om Date of Issuance. Nowork tostart without 48hour notice to the SuperintendentofHighways.
Permit must ~ available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - 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 sufficien0
HFS Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATN:
LOCATION:
TOWN:
WORK CRDER:
~/10D~O6 10:22:'~7 AM
270 BAY AVE
E MAP, ION
T100~M3~36
VILLAGE OF
CROSS ~fREET~ MAIN RD
SURFAC~:
4' x 4' Bell Hole
BAY AVE