HomeMy WebLinkAbout460 Clark RdDate: 04/17/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt: 6484
Transaction(s):
1 1
Permits
Reference Subtotal
439 $170.00
Check#:6484
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 439
~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£#TI00617170
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
l) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant Address
2) 460 Clark Road Name of Owner of Premises Address
Clark Road - bellhole on e/s of Clark Rd. 500' n/o Soundview Avenue
to install a gas service to #460
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __ X __
*lf yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
$)
Plumber's License No.
Other Trade's License No.
Signature of Applicant
04-10-06
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 ora 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: $
Il) 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 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 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-
l.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional Iff ~ .30 =
Excavations 5' in depth and over:
0-lO01.£ $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 Permit to:
KEYSPAN ENERGY DEL1VERY in accordance with this application.
SUPERIbi.T-g~DENT OF HIGI~WAYS
Peter/W ~/arr, is
_
,e t 'ffate
Received by the Town Clerk ,t,/'_ ! '7 - O ,~'
Permit Issued /7/- / 7 ~ O 6- Permit No.
Not~e: Permitexpiresone(I)ycar£romDateoflssuance Noworktostartwithout48hournoticetotheSuperintendentofHighways
Permit must be available Ibr inspection
D-39 Page 2 of 3
Cop'~ Distribution
}-hghway 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)
B!IC- Building under Constmction
WlP Work in Progress
DB Improper backfill (too high) (not sufficient)
HFS- lnspectorholdingforfinalsettlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
~ PERI~T APPLICATION SKETCH
DATE:
LOCATION~
TOWN:
WORK (~RDER:
· 10.,'2f06 1:04:44 PM
SOUTHOLD
T100617170
VILLAGE OF
SUF~ACE:
4' x 4' Bell Hole