HomeMy WebLinkAboutSummit LnDate: 09/15/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 5525
Transaction(s):
1 1
Perm[ts
Reference Subtotal
407 $170.00
Check#: 5525
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 407
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 7653140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100547134
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 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 Tyne
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) Summit Lane, East Marion Name of Owner of Premises Address
3) Summit Lane - bellhole wis grass area~ approx. 266' s/e of Marina Drive~ to install a gas service
at a new house
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 permti~ may be required.
Plumber's License No.
Other Trades L~ense No.
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all other necessa~3~ 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:
Completion Date
D-39 Page I
T100547134
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 lnjury, 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 applications 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.f. = $10.00 -
1.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.£ = $50.00
I.f. @ $0.50 $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided end attached to this application prior to issuance of
permit.
TOTAL COST -- $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Date
Permit Issued ~ '" [ ~' ~9(~ Permit No.
Not~e: Permit expires one (I) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Cony Distribution:
Highway Depamnant
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2.d
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
1L - Improper lights
ST Sunken trench or excavation
UTM- Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB -lmproper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
J=C-6~ 11,4
·PERMIT
NO,
LOCATION
REA$ON FOR.
OPENING
W.OJPA
NO.
REQUE~T~
'BY
~PPROVED
~YSPAN GAS CONSTR~i. ~PAN 531 ?58 Sl~ P.83
REQUEST FOR STREET OPENING PERMIT
MI8 ~08 ~ DATE~ , /
DEPARTMENT DIVISION
~ GAS CONSTR. MAINT. & SERVICES'
DATE
SKETCH