HomeMy WebLinkAbout245 Pike StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/11/06
* * * RECEIPT * * *
Receipt~: 7063
Transaction(s):
I 1
Permits
Reference Subtotal
45;8 $170.00
Check~: 7063
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 45;8
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#TI00660593
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 CONST1L DEPT. - 175 E. OLD COUNTRY RD. - H1CKSVILLE, NY 11801
Name of Applicant Address
2) 245 Pike Street, Mattituck Name of Owner of Premises Address
3) Pike Street - bellhole on S/e sidewalk area approx. 88' s/w of Love Lane to install a gas service to
g245 Pike Street (North Fork Bank)
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.
Electrician's License No.
$)
X
Plumber's License No.
Other Trade's License No.
Signature of Applicant
08-7-06
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 Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Comnletion Date
W.O. gT100660593
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 Injury, and $50,000 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for ant>lications and eermits: 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 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.
s [ ~~.U~DENT OF UmHWAYS
LD, NF~ YORK
x -- -- -- ~'eter W. Hair=is
~ Da~
Received bY the T°wt~_~exk Date
Permit Issued ~7~ <~',~ Permit No.
Not~e: Permit expires one (l) year from Date oflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39 Page2 of 3
CoDy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3rd
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- lnspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
MIS JOB ~'
FOREMA~
DATE OF
~.~.~..~ ~,v,.,~"'"~ ~
GAS CONSTR, MAINT. & SERVICES
DATE
N
TOTAL P. 02