HomeMy WebLinkAbout540 Bayer RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/01/05
* * * RECEIPT * * *
Receipt#: 5745
Transaction(s):
1 1
Permits
Reference Subtotal
416 $170.00
Check#:5745
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 416
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHYVAY EXCAVATION AND REPAIR
Re£#T100559811
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.
PrintorType
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY llg01
Name of Applicant Address
4) Builder's License No.
Electrician's License No.
2) 540 Bayer Road, MaRituck Name of Owner of Premises Address
540 Bayer Road - bellhole on Bayer Road, 148' s/o Conklin Road in front of house #540 in order
to repair a gas leak.
4) Work Description and Location (Street Number, Hamlet, Cross Stree0
(a) ls 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~_ icen~e No~_
Signature of Applicant
10-24-05
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 eovered by this applieation 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
12) Insurance Coverage: (A~ach 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:
13) Secuhty:
a)
h)
T100560335
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
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 1.12 = $10.00 -
I.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.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
Received by the Town Clerk ,~t~) ~b/-O ~
Permit Issued./I-/-o DatePermit No. ~/~>
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.
oNDENT OF HIG/HWAYS
Peter W. Hams
~ 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
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper bamcades
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- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ PF, I~IVHT APPLICATION SKETCH
DATE:
LOCA~I ON:
TOWN:
WORK ORDER:
10~25~2935
~40 BAYER RD
MATTITgCK
T100250335
VILLAGE OF
C~OSS SnIEET: CONI~.IN RD
SIJRFACE:
Macadam Road
NO.
.MO
Bell Hole
BAYER RD