HomeMy WebLinkAbout180 Summit LnDate: 12/09/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt'8: 5934
Transaction(s):
1 1
Permits
Reference Subtotal
423 $170.00
Check#: 5934
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 423
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
ReL#T100573693
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Soutbeld 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 sit~
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
4) Builder's License No.
Electrician's License No.
2) 180 Summit Lane, E. Marion Name of Owner of Premises Address
3) Summit Lane -bellhole n/s grass area, approx. 650' w/o Gus Drive~ to install a gas service
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 Tra~
Signature of Applicant
12-01-05
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 appl.lcation 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
TI 00573693
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
orS
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.f. - $10.00 -
l.f. @ S0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.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 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.
S UPERIN~.T~DENT OF HIGHV'~yAYS
~' -- Peter W. Har~i~--
Received by the Town Clerk -/~j~ ~'-' t Dat[
'Date
Permitlssued /r~/~ J~" PermitNo.
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
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
3rd
4th
Findings (use code)
Applicant Notified
(To Pelmit 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- lnspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ ~ON~T~
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
6~i 958 513S P.O?
FC-6i 11.4
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W,O,/PA
NO.
REQUESTED
BY
APPROVED
r---] STATE ~ NASSAU SUFFOLK
COUNTY ~ COUNTY
MIS JOB~,D &) ,
No.
~'~/~
DATE
FOREMAN DATE OF
DEPA,,..T" D'V'S'%7""G
GAS CONSTR, MAINT. & SERV CES
DATE
SKETCH