HomeMy WebLinkAbout9870 Marlene Lno Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/08/05
* * * RECEIPT * * *
Receipt-8: 5330
Transaction(s):
1 1
Permits
Reference Subtotal
397 $170.00
Check#: 5330
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 397
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100528076
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 York, and other
applicable laws, ordinance~ or regulations for the excavation herein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and 1o 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. - HICKSVII,!,I~_ NY 11801
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 9870 Marlene Lane, Mattituck
Name of Owner of Premises Address
3) Marlene Lane - bellhole e/s paved area~ approx. 260' s/o Main Road~ to install a gas service to
#9870
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes No __X
*If yes, other Town permits may be required.
Plumber's License No.
Other T~e's License ~h~ ~
/Q - ] Sig~ture of ~pplicgan~
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 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 .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
Il) Remarks:
, Lot
Completion Date
1) 39 Page I of 3
T100528076
12) InsuranceCoveraee: (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
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:
0-1001.£ = $10.00 -
I.f. ~ $0. I0 =
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 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
permit.
TOTAL COST = $170.00
Authorization is he/xeby 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
Peter W. Harris
Date
Received by the Town Clerkt ~OC~O ~/-
Pc=it Issued ~50: Pe~t No. S?/
N~: P~it expi~s one (1) year ~om Date of ~suance. No work to sm~ ~thout 48 hour notice to the Supmnt~d~t of High~ys.
P~it must be available for in.chon.
1)39 Page 2 of 3
Couv Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
2nd
3rd
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 Constmction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
10:28
GAS CONSTR
KEYSPAN
FIEQUEST FOR STFIEET OPENING PERMIT
631 958 5136 P,04
MIS JOB
PERMIT
NO,
LOCATION
REASON FOR
OPENING
' FOREMAN DATE OF
' I OPENING
DEPARTMENT DIVISION
GAS CONSTR, MAINT. & SERV CES
DATE
~,¢.,',~-~/,~/- ,o 7-._~
W.O.IPA
NO.
REQUESTED
BY
APPROVED
SKETCH
TOTAL P. 04