HomeMy WebLinkAbout1635 Founders PathTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/30/06
* * * RECEIPT * * *
Receipt~: 6076
Transaction(s):
1 1
Permits
Reference Subtotal
428 $170.00
Check#: 6076
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 428
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£#T100585543
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 nec~sary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 1635 Founders Path, Southold Name of Owner of Premises Address
3) Founders Path - bellhole e/s Old Shipyard Lane, 175' n/o Founders Path~ in order to install a gas
service to 01635
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.
Plumber's License No.
Other Trade'~cense No.
Signature of Applicant
1-05-06
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 tile 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 I of 3
T100585543
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 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:
0-100 1.£ = $10.00 -
l.f. ~ $0.10 =
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
[£ @ $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 Soud~old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk / - ,.~ -O &
Permit Issued / ~ O9~5~ ' 0 (~ Permit No.
SUPERINTENDENT OF HIGHWAYS
Peter W. Harris
! Date
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
Applieam
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- lnspector holding for final settlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
~ PERM/T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
D'N~006 12:11:36 PM
OLD SHIPYARD LN
SOUTHOLD
T100555543
VILLAGE OF
CRO~ STREET: FOUNDEP-~ PATH
/IIRFACE:
Macadam Road
H~e NO.
iai 175'
4 x 4' Bell Hole
OLD SHIPYARD LN
N