HomeMy WebLinkAbout440 Marina LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/08/05
* * * RECEIPT * * *
Receipt~: 5329
Transaction(s):
1 1
Permits
Reference Subtotal
398 $170.00
Check#: 5329
Total Paid: $170:00.
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Intemal ID: 398
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
Ref.#T100529484
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 d~scribed. 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
2)
3)
4)
Name of Applicant Address
440 Marina Lane, East Marion
Name of Owner of Premises
Addr~s
Manna Lane- bellhole n/s grass area, approx. 120' w/o Shipyard Lane, toinstalla gasserviceto
0440
Work Description and Location (Street Number, Hamlet, Cross Street)
(al Is construction located within 75 feet of tidal wetlands? *Yes No
*lf yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other 3[r~de's License No.
S y atnre oeAp i t
07-27-05
Date
a) Attach plot plan showing location of pr#posed excavation and relationship to adjoining premises or
publie 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
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
, Lot
Completion Date
D-39 Page I of 3
T100529484
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 pmvided in the total amount
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. 1 /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.£ ~ $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
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 Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance w/th this application.
SUPERINTENDENT OF HIGHWAYS
TOWJx~OUTHOLD, NEd? YORK
/~Da~ ~.., Date
Received by the Town Cler~k ~t~ x,~ ~t9~
Permit Issued r-~t~t9~'~' Permit No.
/ /
Note: 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 Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
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 - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
JUL-25~-2005
KEYSPRN GAS CONSTR
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
F--]'STATE ~ NASSAU
COUNTY F'~COUNTySUFFOLK
631 ?58 ~i36 P.O~
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W. OJPA
NO.
REQUESTED
BY
APPROVED
FOREMAN ~'~ t'~J'c'~/"~' ~ ~.~,,!-.5' ..)"*~:,~J,~.~ DATEOF
OPENING
DEPARTMENT DIVISION
GAS CONSTR. MAINT. & SERVICES
SKETCH
DATE
.Y
N
TOTAL P. 05