HomeMy WebLinkAbout1145 Fleetwood RdDate:
* * * RECEIPT * * *
Receipt/t: 6555
Transaction(s):
1 1
Permits
Reference Subtotal
444 $170.00
Total Paid: $170,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID:
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
Re£#TI00621758
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. - HICKSV1LLE~ NY 11801
Name of Applicant
2) 1145 Fleetwood Road, Cutchogue
Address
Name of Owner of Premises
Address
3) Fleetwood Road - bellhole on the s/s approximately 150' e/o Betts Road~ to install a gas service
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
04-21-06
Date
a) Attach plot plan showing location of proposed excavation and relatlonship 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: $
l 1) Remarks:
Completion Date
12) Insurance Coverage (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) 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 applications 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 l.f. = $10.00 -
1.~ @ So. lo =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.fi =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.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 the Town Clerk ZIg/-~q.~,- ~2~,
Permit Issued /--..~- ~ '7~ O(~:, Date Permit No
TENDENT OF HIGHWAYS
sotj?oL? y%
Pe/t, er W./Harris
Not__e: Permit expires one (I) year from Date of Issuance. 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 Departmenl
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
COOK
IB - Improper barricades
IL Improper lights
ST - Sunken trench or excavation
U~M- Unable to measure (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
KE~AN GAS CONSTR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
631 ?58 5136 P.02
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
]----] STATE ~ NASSAU ~ SUFFOLK
COUNTY COUNTY
MIS
NO. J°""~'O~
DATE
~) FOREMAN DATE OF
E/o
.EPA.TMENT
~s co.s~...~,.~. · s~.v,c~s
DATE
N
TOTAL P.02