HomeMy WebLinkAbout1350 Marlene LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/27/06
* * * RECEIPT * * *
Receipt'g: 6202
Transaction(s):
1 1
Permits
Reference Subtotal
434 $170.00
Check#: 6202
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 434
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100594749
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 oftbe
job sit~
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
Z) 1350 Marlene La, Mattituck Name of Owner of Premises Address
3) MarleneLane- bellhole w/s side of road 1450' n/o Peconic Bay BIvd to install a gas service to
4)
5)
#1350
4) Builder's License No.
Electrician's License No.
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.
Plumber's License No.
Other Trade's License No.
Signature of Applieant
2-01-06
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 of a Highway Excavation Permit
5)
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Lot
Completion Date
D-39
Pagelof3
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:
13) Secuht¥:
a)
b)
T100594749
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
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-I00 I.fi = $10.00 -
I.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional Iff @ .30 =
D. Excavations 5' in depth and over:
0-100 I.£ = $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 DELIVERY in accordance with this application.
SUPER~--T~DENT OF HIGHWAYS
Peter W. H~s
Received by the To~ Clerk ~~ ~~
a/ r/o
Not~: P~it expires one (1) year ~om Date of Issuance. No work to sm~ ~thout 48 hour notice to the Superintendent of Highways.
Pemit must be available for in~ecfion.
D-39 Page 2 of 3
~ PF,~MIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
2/3f2006 2:47:15 PM
1350 MARLENE LN
MA/q/TUCK
T100394749
VILLAGE OF
CROSS SI~EET: PECONIC BAY BLVD
~3RFACE: ~
m
rn
0
I{.~. NO.
1350
la~0' /~
4 x 4' Bell Hole
MARLENE LN
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
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)
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