HomeMy WebLinkAbout670 Youngs AvePermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00661879
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 CONSTIL DEPT. - 175 E. OLD COUNTRY RD.- HICKSVILLE. NY 11801
Name of Applicant Address
2) 670 YoungsAvenue, Southold
Name of Owner of Premises Address
3) Youngs Avenue - bellhole on E/s approx. 250' s/o of Main Road to install a gas service to g670
Youngs Avenue
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.
Electrician's License No.
X
5)
Plumber's License No.
Other Trade's License No.
Signature of Applicant
08-'/-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 appllcation 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. #T100660593
12) Insurance Coverane (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) Securit-/:
a) Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /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 -
I.f. ~ $0.10 =
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 I.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 thc 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
TOW T.Om NE W/XOP
/ Date-
Received by the Town Clerk
~.~/¢ Date ,~/r~
PermR Issued ~, Permit No.
Not__e: Permit expires one (1) year ii-om Date oflssuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3~d
4th
Findings(use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB- Improper barricades
1L - Improper lights
ST - Sunken trench or excavation
UTM- Unable to measum (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
KEYSPAN GAS CONSTR
K£YSPAN
R£QUEST FOR STREET OPENING PERMIT
f---] STATE I---1NASSAU
COUNTY F-~SUFFOLK
COUNTY
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
FOREMAN
MIS JOB . DATE
REQUESTED DEPARTMENT
BY GAS CONSTR. MAINT. & SERVICES
APPROVED
SKETCH
DATE OF
/
DIVISION
DATE
EMERGENCY
INSTALLATION
NO oT'
N
TOTAL P.92
IHick~e, NY 1'1801
Fee Amount:1 $170,00
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAOEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
=/f 6/5--6
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
FAX TRANSMITTAL
To-'
From:
Dated:
Re:
Linda - Gas Dept. - Keyspan Energy
5116-545-4474
Linda J. Cooper, Deputy Town Clerk
August 8, 2006
Rush Highway Excavation Permit
Number of Pages (including cover): 6
If total transmittal is not received, please call 631-765-1800.
COMMENTS:
As you requested, the permit was rushed through the process. It has been issued permit no. 456
Please remit the payment of $170 to the Southold Town Clerk immediately.
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/08/06
* * * RECEIPT * * *
Transaction(s):
1 1
Permits
Reference
456
Subtotal
$o.oo
Cash
Total Paid:
$0.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 456
08/08/2006 TIlE 10:02 FAX
[~001/006
'row-a of Sou~ol(I
275 F~coalc/.a.ue. P.O. JE~x 178
Pecoak. ~teW York 1 ]95JJ
PETER W. HARRIS
' -- -- SUPURINI'~.NDHNT OF HIGHWA'I'S
FAX CO ER SI-IEI{T
FAX TO:
E.L'( NUNI}IER;
DA'I'~:
NIJNI~ER O1,' PAGES:
FROM:
SO[/THOLD TOWN HIGHWAY DI,:FAR'I'MENT
COM-M]EN I'$:
...... ~. _ '; .. ~9
SHOULD YOD HAVE ANY Q0'ESTIONS, OR PROIfLEM'$ RECEIVINg 'I'ItlS
I;AX 'fltANSNI1TTAL, PLEASE E1TITER PHONE (6.31)78~3140 OR
I;'AX ( 63t)765-1750.
08/08/2006 T~ 10:02 FAX
~8/06 '~6 TL~ 09:26 FAX 631.76
L45
~1~ No._ L//~ ~ -
~004/006
SOUTHOLD TOWN CLE, RK -~-+-+ }{ighwa.n' DepE ~003
F~X ~ ....................
..... ,'.? ;"d' '"':.',;':;~:?¢'~ ""'";?:: ": ·
· ..... .'.' .. , :......-~;.:.:.;.. .,..,.:.......-:. PR~ 3/
TOWN OF ~OUT~OLD ~
4)
4)Belldcr,~ Lfcca~c No, ~
~le~trjela k,,~l Lite, ac NO. ~
Work D~c~ipUo= aad Location (Street NOmber, ~amlc(, Cr=~ Street)
qlf~ a berToWa~Jama.,~ ~o~
, ~umb~'s Lic~e No. ~
$1g~eturc
,s apphcatma may nat ¢Ommeu~ before I~uanec ora lligbway ~Va~oa Permit
7) S~/ngDa~: ~Lot~
~) Work Schedule:
SOb~l~HOnP TO~N CLERK
005/006
~oo4
P~E 4/
SlSO.OO
0-100 I,E
l.~ ~ SO. tO =
O-lOn Lf- =
AddidvnaJ ~ ~.30~=
08/08/2006 TUE lo:o2 FAX
05/08' '66 TUE 09;28 FAX 631,?fl 4~ SO~TTHOLD TOWN cLERK
F]LE No.:,SSS 08~08 'QB 07:?~ FAX:
~G-~'?-2F~,E, 8=:57 KEY~PAH G~S C-~NSTR
[~]003/006
Highway Depz ~]002
KEYS. PAN
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO,
LOCATION
REQUESTED
BY
APPROVED
[~--~'~TATE
[] NASSAU
COUNTY
SUFFOLK
GOUNTY
EI~GENCY
INSTALLATION
NO
DATE OF
IDIVISION
N
TDI'~L P. (~2
08/08/2006 TUE lo:03 FAX
o~/08''~ T[~ 09:27 FAX 631,76~45
F~LE No:,5~5 08,,'0~ '0~ 07:~7
$OUTHOLD TO~N CL.__.E.A~_
~:
006/006
~o0s
t~
-)rd
Fi~din~ (usc o:~c)
Appti=m~ No6~ged
(Ta P~lt Oink)
08/08 '06 TUE 09:27 FAX 931 765 6145 SOUTHOLD TOWN CLERK ~001
*** TX REPORT ***
TRANSMISSION OK
TX/RX NO 2791
CONNECTION TEL 97651750
CONNECTION ID Highway Dept
ST. TIME 08/08 09:26
USAGE T 01'29
PGS. SENT 5
RESULT OK
FILE No.SSS 08/08 '06 07:3~ ID: FP>:::
PAGE 1/ S
Energy DeliVer-'"
Co,/Dep. L ,
Phons
Fax #
FILE No.585 08/08 '06 07:36
F~X:
Permit Ne.
File blo,
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pe¢onk Lane
Peeonic, New York 11958
(631) 765-3140
APPLICATION/p~RMIT FOR HIGI~VAY EXCAVATION AND REPAIR
]~e~#T100661879
APPL]CATION 1S HEIK~B¥ mede to the SupefiMendeaf Of H~bway. of the Town ~ ~ufhMd for the i~nce of
appll~ble ]awk ordiaa~ or ~uIidoM for ~e tx~va~ b~in d~ri~. ~z np~lgant agrzo ~ c~ply wi*b ati
appliflble laws, ordlnan~ c~fl and ~olaflous. and ~ ~rmit authored iM~mfl to ma~ n~c~ in~cfions of thc
Print or T~I~
1) KEYSPAN itNERGY- OAS CONS~ D~. - 1TS E. OLD COU~Y ~. - HICKSV~LE. NY 11~1
Name ~Ap~nz ~dr~
2) 670 Youn~ Avenu~ ~u~old Name of~ner of Premiss Address
'~) Youngs Avenue -~be[]bolg o~ ~/s approx. 250' a~p of Main Road to inmta]] ~ tqs service to 0670
Youn~ Avequ¢
PRGE 3/
5
4) Work Description and Location (Strut Number, Hamlet, Cross Street)
(a) IS consWuttion located wlthio 7S feet of tidal wetlands? *Yt~ No
'If yes, other T~n ~rml~ may ~ required.
4)Builder's Li~nse No. Plumber's License NO.
El~rieian*s Li~nse No. ~her Trade's Liccn~ No.
X
Signature of Applicant
Date
S)
a) Attach pint plan showing location of proposed Rcavation and relationship to adjoining premise~ or
public streets or areas, and giving e detailed d~cripfion of layout of excavation.
b) A~ch all ether nece~a~ permi~ and Ibens~ for this prM~.
c) Work covered by this applicat~on maynotcommencebefore~uanceofaHJghwayExcavationPermlt
by tho Town CI~
6) Tax Map: Section
7) Starting Dnt~:
, Block , Lot.
Completion Date;
Work Schedule:
~phq~e ComelVion Date
Excavafioa ...............................
:F~eltiW tnmmllatioD ...............................................................
Back~ll & ~ompe~.'lo~ ...............
Pavement Replacement ......................................................... __
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: S
Il) Remarks:
FILE No.585 08/08 '06 07:37
FAX:
PRGE
a) Insotnnce Company:
b) Policy #
c) Sta~ whethgr poticy of certLqcalion on I'il¢ with the Highway D~-partmanI:
,4) Covcra&~ reqUirr, d extended to the Town;
Bodily in~ory m-4 prope~ damage; $300,000~500,000 l~dily Injury', and $50,000 prop~t*y damage.
a) Sumt~ Bond or Certified Ch~:k
b) Malmcnaa~ Bonded provided: :2 y~ars or
] 4.) Fe~s for aoolienlions and .nermiu: ]~lsi¢ ADoIicaIioo Fee
Al.
/Additional Excavations samo service q~l $10.00 =
provide~i in the m~al amoum
3 ycars
~1~0.00
B. Excavations 18" in depth ar
0-100 I.f, = $1o.00 -
.i,r, ~ SO. t0=
Additional
E~.c~vations 18" in d~th to .~' in d~pth;
~-100 Lf.=
A~itiomg If. @ 30 -
I~xcavat'Jons 5' in d~th and over:
O- ! 00 Lf. = SS0.CO
I.f, ~) So.5o ~- S
A~ditional
E. Utility Repair Excavalions ~ $10.00 = $
No.
Repairs same s~rvi¢c ~ $5.00 = S
Additional
F, Notice to public ~lilitles proof must bc provided and atlached to this application prior to issuance of
permit.
Siva
TOTAL, COST = $170.00
4/ 5
Au,Jlol~ad on is hereby gtanltd to ~c Town Clcrk of the Town of Southold to iSsu= ti Highway Excavation permit w:
~ySpAN ENERGY DELIVERY in a~xdan~ with this application,
SUPEILTNTI~NDElqT OF HIGHWAYS
TOWN OF SOUTHOLD, NI~W YORK
P~r W. Harris
Rccciyrd by th~ Town Clerk
Permit Is.sued P~rmit No.
Nora: Pcnnit rnp L, cs one (1) year from Dat~ of IssuanCe. No work to stun without 48 hour no6ce m thc Supcrint~nd~t of Flighwa~.
Permit m~*t be av~]~lc for inspection.
Poge 2
FILE No.585 08×08 '08 07:37
Cotlv Distribution:
Hi~w~y Depart:merit
Appli~nt
Town Clerk
FAX:
PAGE
5/ 5
iNSPECTOR'S R~CORD
Insp~;fion
Findings (us~ cod~)
Applicant No~ifi~
(To Permit Clerk)
lB- Improper barricades
IL - Improper light~
ST - Sunken U~-nch or excavation
UTM - Unable ~o measure (due to back~{ling)
BUC - Buildlng under Consttu~ion
WIP - Work in ProgcsS
DB - Improper backtlll (too high) (not suificient)
HFS- Insp~ctorholding forfinal s~l~m~nlof~cavaiion
RFR- R~.i~clym R~pldr
Page 5 of 3
F]LE No.585 08/08 '06 07:36 ...,~: FAX:
1 ~LtG-Cd;7-2006 03:374~;PRN GR8 CONSTR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
P~GE 2/ 5
p 0o
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O,/PA
NO.
REQUESTED
BY
APPROVED
~---]'STATE
SKETCH
NASSAU SUFFOLK
COUNTY ~ COUNTY
~15 JOl~ DATE
,,, NO. TIO0 (,,~1~.99
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
DATE OF
EM . RGENCY
INSTALLATION
NO
N
TOTAL P. 02