HomeMy WebLinkAbout1780 Gillette DrDate: 11/01/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 5748
Transaction(s):
1 1
Permits
Reference Subtotal
415 $17O.00
Check#: 5748
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 415
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100562941
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South#Id for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South#Id, 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 ! 1801
Name of Applicant Address
2) Gillette Drive, E. Marion Name of Owner of Premises Address
Gillette Drive - bellhole e/s grass area~ approx. 472' n/o Cleaves Pt. Rd, in order to install a ga~
service to #1780.
4)
4) Builder's License No.
Electrician's License No.
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~
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 covered by this application may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section ., Block
7) Starting Date: Completion Date:
8) Work Schedule:
, Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Pr#posed Work: $
11) Remarks:
T100562941
12) lnsur~aceCoverage: (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 avvlications and pemaits: 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. @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-I00 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 1.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 wanted to the Town Clerk of the Town of Southold to issue a Highway Excavation P~mit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk /O - 3/-O~"
Permit Issued /ff~/~0 ~ Date Permit No.
SUPERINTENDENT OF HIGHWAYS
Peter W. Harris
t Da~
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
Co~v Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~
3~a
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfiIling)
BUC Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for finalsettlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN GAS CONSTR 651 ?58 5136
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO,
REQUESTED
BY
APPROVED
SKETCH
r---~ STATE ~COUNTyNASSAU F-~ SUFFOLKcouNTY r~ MIS J OB....-~". -
FOREMAN ' DATE OF
~ GAS CONSTR. MAINT. & SERVICES
DATE
N