HomeMy WebLinkAbout380 Kimberly LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/22/05
* * * RECEIPT * * *
Receipt~: 5483
Transaction(s):
1 1
Permits
Reference Subtotal
408 $170.00
Check#: 5483
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 408
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£#T100545114
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 ag~es 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 Tyne
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVII.LE_ NY 11801
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 380 Kimberiy Lane, South#Id Name of Owner of Premises Address
Kimberly Lane - bellhole e/s Kimberly Lane~ 400' n/o Roxanne Road~ to install a gas service at
0380
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.
Other Trnde'~License No.
'gnat ur;9°.~6A.0Psplicant /~/
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 maynotcommencebeforeissuanceofaHighwayExcavationPermit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Pr#posed Work: $
11) Remarks:
· Lot
Comoletion Date
D-39 Page I of 3
T100545114
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 end property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Secudt¥:
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 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 l.fi = $10.00 -
1.£. @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f. =
Additional Iff ~ .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 Town of Southold to issue a Highway Excavation Pe~,it to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk q - t~ ~'
Permit Issued ~--0~ ~ hO'~" Da*e Permit No.
SUP ERjl~I.~END ENT OF HIGHWAYS
TO~ ~. ~N~/OUTH LD, NE ORK
~' ~'eTcr W. [tams ~'
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 Page2of3
Coov Distribution:
Highway Deparanent
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
~ PF, R_MIT APPLICATION SKETCH
DATE:
LOCATI ON:
TOWN:
WORK ORDER:
~0 KIIvMERLY LN
$OUTHOLD
TI00545114
VILLAGE OF
SIREET: ROXKNlqE RD
6[~.FACE:
Macadam P~ad
H~e NO.
~0
KIMBERLY LN