HomeMy WebLinkAbout425 Summit DrDate: 02/24/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt~: 6169
Transaction(s):
1 1
Permits
Reference Subtotal
432 $17O.OO
Cash#: 6169
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 432
Permit No.
File No.
HiTOWN OF SOUTHOLD
GHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100592049
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. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 425 Summit Lane, East Marion Name of Owner of Premises Address
3) Summit Lane - bellhole w/s grass area~ at the i/o Marina Lane~ to install a gas service to g425
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. Plumber's License No.
Electrician's License No.
Other Trade's License No.
Signature of Applicant ! /
1-27-06
Date
5) a) Attachpl~tplansh~wing~cati~n~fpr~p~sedexcavati~nandrelati~nshipt~adj~iningpremises~r
public streets or ureas, 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 ~ Block , Lot
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:
Completion Date
D-39 Page 1 of 3
T100592049
12) Insurance Coveraee: (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. 1 /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.£ @ S0.10:
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 1.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 aRached 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 Pc-rmit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk tg~/~ ~
Permit Issued oc~/~ ~.. Date Permit No.
SUPERINTENDENT OF HIGHWAYS
TO~'~JF'S, OUTHOLD, NEX~V YORK
Peter W. Hams
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
Cony Dis~bution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper bamcades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC- Building under Constmction
WIP - Work in Progress
DB lmproper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
K~¥SP~N ~S ~ON~TR 6~ ?58 5~6
KEYSPAN
REQUEST FOR STREET OPENING pERMIT
PERMIT
NO.
LOCATION
REASON FOR
OPENING ,
~-'"~ STATE ~] NASSAU
cou.T¥ ~ SUFFOLK
/
MIS JOB DATE . .
NO, "77'~...¢'¢'~,¢'"/? ~/~-¢-/~
W.O./PA
NO.
FOREMAN
REQUESTED DEPARTMENT
BY GAS CONSTR, MAINT.& SERVICES
APPROVED
DATE OF
OPEN NG /Z~,~Z~?
DIVISION
DATE
SKETCH
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