HomeMy WebLinkAbout2765 Highland Rd Town Of Southold
OS 1179
P.O
Box
outhold, NY 11971
Date: 01/04/06
* * * RECEIPT * * *
ReceiptS: 5994
Transaction(s):
1
Permits
Reference Subtotal
427 $170.00
Check#: 5994
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 427
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
Ref.#T1005778635
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 Yorl~ 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
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 2765 Highland Road, Cutchogue Name of Owner of Premises Address
3) Highland Road - bellhole w/s Highland Road~ 125' s/o Crown Land Lane~ in order to install a
gas service to #2765
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's Lieense No.
Other Trad~~. U ~.~--~--~-~
Signature of Applicant
12-14-05
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
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 1 of 3
T100578635
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 proper~y 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. 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. = $I0.00 -
l.f. ~ $0.10
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l£ =
Additional I£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 1.£ = $50.00
1.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 Excava ion Perm t o
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk /- g'/- O f'
Date
Permit Issued /- c/~ O &-, Permit No.
S UP ERIN.,T.F~N T OF~IGHWAYS
Z
-~et~r W. Harris
Date / -
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
Inspection Date
l~t
3fa
Findings (use code)
Applicant Notified
(To Permit Clerk)
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 - lmproperbackfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ PERM/T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
12514~2~8J
276~ HIGHLAND RD
CUTCHOGUE
T1011575633
VILLAGE OF
STREET: CROWN LAND LN
S~.FACE:
Road
House NO.
2765
W'~ 125'
Bell Hol~
o
HIGHLAND RD