HomeMy WebLinkAbout720 Mechanic StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/24/05
* * * RECEIPT * * *
Transaction(s):
1
Permits
Check#: 5683
Receipt~ 5683
Re~414~/ Subtotal
$183.60
Ttal~: $183.60
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC internal ID: 414
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#T100552344
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 d~cribed. The applicant agrees to ~omply with all
applicable laws, ordinances, coda and regulations, and to permit authorized inspectors to make necessary inspeetions of the
job site.
Print or Type
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLF._ NY 11801
Name of Applicant
2) 720 Mechanic Street, Santhold
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
Address
Address
Mechanic Street - bellhole w/s paved area~ approx. 630' s/o Main Road~ and a 112' trench south
in pavement to install a gas main and service to #720
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.
OtherTra
Signature of Applicant
10-13-05
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) W~rkc~veredbythisapplicati~nmayn~tc~mmencebef~reissuance~faHighwayExcavati~nPermit
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:
Comuletion Date
D-39 Page I of 3
T100552344
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 anolications and ~ermits: Basic Application Fee
A 1. /Service Connections excavations ~ $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:
0-1001.£ = $30.00 (100') =
12 add'l 1.£ ~ .30 = (trench is 112')
$30.00
3.60
Additional
D. Excavations 5' in depth and over:
0-1001.f. = $50.00
1.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 allached to this application prior to issuance of
permit.
TOTAL COST = $183.60
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.
SUPE~I~ENDENT OF HIGHWAYS
TOFN o ouryoLD, miry ¥OP
Peter W. Harris
Received by the Town Clerk ,/~D/49 ~/,~? ~
perrmtlssued /ot~/Cr.~ Date PermitNo. ~'~// ~
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Supehntendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
CODy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - 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- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN
REQUESt; FOR STREET OPENING PERMIT
FOR , . .
] ~S CONSTR. MA~NT. & SERVIGES I
~±SNOD S~B N~dSAB~
P~: £0