HomeMy WebLinkAbout595 Summit LnDate: 02/24/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
ReceiptS: 6170
Transaction(s):
1
Permits
Reference Subtotal
431 $170.00
Check#: 6170
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 431
Permit No.
File No..
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100592025
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southoid 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. - HICKSV1LLE~ NY 11801
Name of Applicant Address
2) 595 Summit Lane, East Marion Name of Owner of Premises
Addr~s
Summit Lane - belihole s/s side of cul-de-sac in the grass area~ approx. 225' n/w of Marina Lane~
to install a gas service to #595
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.
1-27-06
Date
5) 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
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 .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39 Page I of 3
T100592025
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 armlications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 = $20.00
$150.00
A2. /Additionai 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.f. =
Additional Iff ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.fi @ $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 -- $170.00
Authorization is hereby granted to thc Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit lssued 4,,~ ~ Date
Permit No.
SUPERINTENDENT OF HIGHWAYS
TO~OUTH~OLD, N EsV/'Y ORK
- Peter W. Harris t.,
/ Da~e - -
Not__e: Permit expires one ( 1 ) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
lnspecfion Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB Improper barricades
IL - Improper lights
ST - Sunken n-ench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP Work in Progress
DB Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
JAN-24-~O~
PERMIT
NO,
0?:0?
KEYSPAN GAS CONSTR
KEYSPAN
RE~IUEST FOR STREET OPENING PERMIT
NASSAU [] SUFFOLK
COUNTY COUNTY
758 5136 P.04
~--~$TATE ~
REASON FOR ~ '
~ DEP~RTMENT DJV~S1ON
APPROVED ~ ~ GAS CONSTR, MAINT. & SERVICES ~DATE
SKETCH