HomeMy WebLinkAbout8500 Sound Ave No. t JO
i,c No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100572836
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) 8500 Sound Avenue, Mattituck Name of Owner of Premises Address
Sound Avenue -bellhole s/s grass area, approx. 900' s/e of Middle Road, in order to install a gas
service to #8500
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 License No.
Other Trade's icense NT~
Signature of Applicant
11-17-05
Date
5) a) Attachpl~tplansh~wingl~cati~n~fpr~p~sed~xcavati~nandre~ati~nshiptaadj~iningpremises~r
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
T100572836
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 anvlications 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 l.f. = $10.00 -
1.f. @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
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 Tovm Clerk of the To'am of Southold to issue a Highway Excavation Pe~,i t to:
KEYSPAN ENERGY DELIVERY in accordance with this applicahon.
Received by the Town Clerk [~/~10~~''
Permitlssued ~,,O ~,~.!~.!t~''~ate PermitNo.
SUP~.II~TENDENT OF HIGHWAYS
Note: Permit expires one (1) year from Date oflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspechon.
D-39 Page 2 of 3
RUSH
REQUEST FOR STREET OPENING PERMIT
STATE ~ NAURU . SUFFOLK
MI~ JOB DATE
FORE~AN ' DAT[ OF
[ GA8 ~NSTR. MAI~. &SERVICES ,
NOV-16-2005 02:13
PERMIT
NO,
LOOATION
REAEON FOR
OPENING
W.O,/PA
NO.
REQUESTED
BY
TOTAL P.05
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 12/02/05
* * * RECEIPT * * *
Receipt~: 5882
Transaction(s):
1
Permits
Reference Subtotal
42O $170.00
Check#: 5882
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 420