HomeMy WebLinkAboutGus DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/29/05
* * * RECEIPT * * *
Receipt~: 4730
Transaction(s):
Permits
Reference Subtotal
377 $170.00
Check#: 4730
Total Paid: $170,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 377
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
Re£#T100474996
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. - HICKSVII .I .E~ NY 11801
Name of Applicant Address
2) Gus Drive, East Marion
Name of Owner of Premises
Address
Gus Drive - bellhole n/s grass area, approx. 120' w/o Summit Lane, to install a gas service to lot
#26
4)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*ff yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
No X
Plumber's License No.
Other T~~
e Signat~t~e of Appl~ant
~/03-18-05
Date
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 ~ Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
Il) Remarks:
D-39
Pagelof3
T100474996
12) Insurance Coverane: (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 end permits: Basic Application Fee
Al. I /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.£ = $10.00 -
l.fi @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi =
Additional lf. ~ .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 granted to the Town Clerk of the Tovma of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPER~b~DENT OF HIC~IWAYS
Received by the Town,Clerk1_ .~f f ._~ ~ 5)~0/( ate
.57?
Peter W. Hams
Date
Not~e: 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 Depariment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARK~
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
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.IPA
NO.
REQUES¥~D
BY
APPROVED
SKETCH
GAS CONSTR 631 758 5136
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
P. 02
~'~STATE
~ NASSAU
COUNTY J~ SUFFOLK
COUNTY
MIS JOB ,~? -- ,
NO.'71t O
FOREMAlq
DEPARTMENT
GAS CONSTR, MAINT, & SERVICES
OATbI /
N
TOTAL P.02
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/24/05
Receipt~: 5685
Transaction(s):
1 1
Permits
Check#: 5685
Ref~ Subtotal
$170.00
TotlP~_~d: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 413
Permit No. t .~
FileNo. ~I
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100557328
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 mal~e necessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVll J J~- NY 11801
~)
3)
4)
Name of Applicant Address
Gus Drive, East Marion
Name of Owner of Premises
Address
Gus Drive - bellhole in grass arean approx. 180' s/o of Shipyard Lane~ to install a gas service at
01250
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction Ioca~d within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
No X
Plumber's License No.
Other TradeS, License No.
Signature of Applicant
10-13-05
Date
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
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
T100557328
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 ~ $20.1!0 = :$20.00
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 1.£ = $10.00 -
1.£ ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.£ =
Additional 1£ ~ .30 =
D. Excavations 5' in depth and over:
0-1001.£ = $50.00
1.£ ~ $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 thc Town of Southold m issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit Issued /0/~,//o I~ Date Permit No.
SUPERjJ~NDENT OF HIGHWAYS
Peter W. Harris
Not~: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to thc Superintendent of Highways.
Permit must be available for inspection.
D-39 Page2of3
Coov Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
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 backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
STATE~ NASSAUSUFFOLK
cou.TY~ OOUNTY
P~NRoM.IT
LOCATION
REASON FOR
O~EN,N~
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
FOREMAN -- DATE OF
· OPEN NG
DEPARTMENT DIVISION
GAS CONSTR, MA NT. & SERVICES
DATE,
N
~O'd 9£~ 8~ Z£9 ~ISNOD S~ N~dSABH ~:60 ~00~-~0-i30