HomeMy WebLinkAbout855 Kimogenor Point RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/17/06
* * * RECEIPT * * *
Receipt#: 6365
Transaction(s):
1
Permits
Reference Subtotal
436 $170.00
Cash#: 6365
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 436
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[#T100605646
APPLICATION IS HEREBY made to thc 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. - HICKSVII J.E. NY 11801
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 855 Kimogenor Point Road Name of Owner of Premises Address
3) Kimonenor Pt. Road - bellhole on s/s of Kimo~enor Pt. Rd. 300' w/o Jackson Street
to reconnect a gas service to #855
EMERGENCY - Customer has no heat
4) Work Description and Location (Street Number, Hamlet, Cross SWeet)
(a) is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No.
Signature of Applicant
03-08-06
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
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:
Completion Date
12) Insurance Coverage (Atiach 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 oermits: 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
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional lf. ~ .30 =
D. Excavations 5' in depth and over:
0-1001.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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
Peter W. Harris
-- ~
Received by the Town Clerk
Permit Issued ..~7/g7 ~' Date
_ Permit No.
!
Not~e: Permit expires one (1) year fi.om Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
2~
4th
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final set~lement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
~ PERM/T APPLICATION SKETCH
DATE;
LOCATION:
T OWN:
WORK (~DER:
3/9.,~ 066 7:~:16 AM
855 KIMOGENOR POINT
NEV7$ UFFOLK
T100605646
VILLAGE OF
C~OSS S~RZET: ~ACKSON ST
SURFAC~:
Mac~iam Ro~i
I~ NO.
855
4' x 4' Bell Hol~
KIMOGENOR POINT