HomeMy WebLinkAbout3430 Wickham AveTown Of Southold
P.O Box 1179
Southo[d, NY 11971
Date: 04/03/06
* * * RECEIPT * * *
Receipt#: 6435
Transaction(s):
1 1
Permits
Reference Subtotal
437 $170.00
Check#: 6435
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 437
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#T100612250
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of S~uthold 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 permiI authorized inspectors to make necessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 3430Wickham Avenue, Mattituck
Name of Owner of Premises
Address
3) 3430 Wickham Avenue-bellhole and a 300' w/o Marys Road~ to install a gas service to #3430
4) Work Description and Location (Street Number, Hamlet, Cross Stree0
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __X __
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
s)
Plumber's License No.
Other Trade's License No.
Signature of Applieant
03-24-06
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
poblie 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:
Completion Date
D-39 Page 1 of 3
T100612250
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
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $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 I.f. = $30.00 (100') = (100' trench)
110 If. ~ .3O =
30.00
33.00
Additional
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 = $213.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit m:
KEYSPAN ENERGY DELIVERY in accordance with this application.
STUP~t~qT~N DTEHNoT ?DF H~I~wH yW~) Y q
'~Pqer W.~)txis k~
v Da/E
Received by the Town Clerk ~,~ ~d9 ff~
Permit lssued ,(_///~ ~ t:~7~r~ DatePermit No. ~r,_fl 7
Note: Permit expires one (1) 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 Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3rd
4th
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- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK
3f24/2~t~ 2:07:01 PM
3430 WICKH AM AVE
MATI%T0'CK
T100~12250
VILLAOE O1~
~.0~ ~TREET: MAP, TS P,.D
M~cad~nRoM
H~e NO. ]
343O
4' x 4' Bell Hob
WICKHAM AVE