HomeMy WebLinkAbout5390 Peconic Bay Blvd )wn Of Southoid
P.O Box 1179
Southold, NY 11971
Date: 12/09/05
* * * RECEIPT * * *
Receipt#: 5959
Transaction(s):
1 1
Permits
Reference Subtotal
425 $170.00
Check#: 5959
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LiNDAC Internal ID: 425
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£#T100577426
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
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 5390 Peconic Bay Blvd, Laurel Name of Owner of Premises Address
3) Peeonic Bay Blvd - bellhole e/s Peconic Bay Blvd~ 635' n/o Birch Drive~ in order to install a gas
service to #5390
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 Tr~
Signature of Applicant
12-06-05
Date
5) a) Attach plot plan showing location of proposed cxcavation and relationship to adjoining premises or
publie streets or areas, and giving a detailed deseripfion 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 I of 3
T100577426
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 perm/ts: 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 leas:
0-1001.f. $10.00-
l.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional lf. @ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
l.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 the 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
/~///V0 Date
Permit Issued d-' Permit No.
SUPERINTENDENT OF HIGHWAYS
TOX3Fjn~"~UTH 0 LD, NEy,/YORK
Peter W. Harris
Note: Permit expires one (I) 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
1st
2~d
3rd
4·
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
IB Improper barricades
IL - Improper lights
ST Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WlP - 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
~ PERM/T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
1256~2(D3 10:3~:06 AM
~390 PECONIC BAY BLVD
LAUREL
T100577426
VILLA GE OF
CRO~ SrREET: BIi~H DR
SIJRFACE:
I-lc ~e NO.
PECONIC BAY BLVD
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