HomeMy WebLinkAbout335 Rochelle PlPermit
File No.
TOWN OF SOUTHOLD
HIGHYVAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100554060
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter g3 of the Code of the Town of Southold, Suffolk County, New Yorl~ 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
Name of Applicant Address
2) 335 Rochelle Place, Mattituck Name of Owner of Premises Address
3) Rochelle Place - bellhole s/s Rochelle Place~ 100' e/o Salt Lake Lane~ to reconnect a gas service at
#335
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's L'ke/ense No.
Signatur;9o. f27A25Plicant
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 beforo 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 Proposed Work: $
11) Remarks:
D-39 Page 1 of 3
TI 00554060
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
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aonlications 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 I.f. = $10.00 -
I,f. @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional Iff @ .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
peamt.
TOTAL COST -- $170.00
Authofizati,,m 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.
Received by the Town Clerk I 6 ' ~.'O ~
Permitlssued tt''~'O~ Date PermitNo.
qll
SUPE~DENT OF HIGHWAYS
P~er W. Hams
Note: Permit expires one (1) year from Date of Issuance. No work I~ start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
I)-39 Page 2 of 3
Co~v Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
]st
2nd
3~
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- lnspectorholdingforfinalsettlemcntofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ PERM/T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
9f27f2005
335 RDCHF; ;~ PL
MATUTUCK
VILLAGE OF
SrREET: SALT LAKE LN
:~JRFACE:
Here NO.
33~
l~ 100'
Bell Hole
ROCHELLE PL
Town Of Southo[d
P.O Box 1179
Southold, NY 11971
Date: 10/03/05
* * * RECEIPT * * *
Receipt#: 5603
Transaction(s):
1 1
Permits
Reference Subtotal
411 $170.00
Check#: 5603
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 411