HomeMy WebLinkAbout530 Bay AvePermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100495470
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 Soutbeld, 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 oftbe
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11901
Name of Applicant Address
2)
3)
4)
530 Bay Avenue, East Marion
Name of Owner of Premises
Address
Bay Avenue - bellhole w/st approx. 510' s/o Main Road, for a gas service installation
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.
4) Builder's License No.
Electrician's License No.
Plumber's License No.
' (3~ignatu~ of A6pl~cant~ v 05-23-05
Date
5) a) At~ach 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 ...............................................................
Back~ll & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Comoletion Date
D-39 Page 1 of 3
T100495470
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 ~ $20.00 = $20.00
$150.00
A2. /Additional Excavations same service @ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.£ = $10.00 -
I.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional I£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.£ = $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 attached to this application prior to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Towa of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permitlssued
'gllS't05''''°ate PemtNo.
SUPERllqTENDENT OF HIGHWAYS
/Pe~:~at~eer W. Harris
Note: Permit expires one (l) year from Date of lssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways,
Permit must be available for inspection.
D-39 Page 2 of 3
MAY-22-2005
08:39 KF=,~SPAN GAS CONSTR 631 ?58 5136 P.03
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W.O./PA
~,T~TE ~ .ASSAU SUFFO.. ~/~
cou.TY
COUNTY
MIS JOB~
FOREMAN
tDATE OF
NO.
REQUESTED DEPARTMENT
BY GAS CONSTR. MAINT.& SERVICES
APPROVED
DIVISION
DATE
SKETCH
TOTAL P.05
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/15/05
* * * RECEIPT * * *
Receipt#: 5053
Transaction(s):
1 1
Permits
Reference Subtotal
405 $170.00
Check#: 5053
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 405