HomeMy WebLinkAbout245 Pine Neck RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/08/05
* * * RECEIPT * * *
Receipt#:
5271
Transaction(s):
1 1
Permits
Reference
395
Check#: 5271
Total Paid:
Subtotal
$170.00
$170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 395
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£#T100522932
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, 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 Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) Pine Neck Road, Southold
Name of Owner of Premises Addr~s
Pine Neck Road - 4'X4' bellhole on s/s of Pine Neck Road~ 271' e/o Main Bayview Road for a gag
service to #245
4)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
No X
Plumber's License No.
Other~r~~~e's License . 7-'~/9~-~"~'.~
! Si~ture o f ~{l~plica~t
"~ 07-13-05
Date
s)
a) Attach plot plan showing location of proposed excavation and relationship to edjoining 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 cove~ed 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:
S) Work Schedule:
, Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Comoletion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39 Page 1 of 3
T100522932
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
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 hf. = $10.00-
1.£ ~ $0.10 -
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional lf. ~ .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
Authohzation is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Perrmt to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk )
Permit Issued ~f/~'~O~5~ Date Permit No. %iQ ,~
SUPE~..ENDENT OF HIGHWAYS
TOi~N OF ~OUTHOLD, NEW Y~)RK
Peter W. Harris
Date
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
l~t
2nd
3~d
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - 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 of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATE:
LOCATI ON:
TOWN:
WORK ORDER:
7513f2~J 11:0~ :23 AM
24.5 PINE NECK RD
SOUTHOLD
TI00522932
VILLAGE O1~
CROSS SrREET: MAIN BAYVIEW RD
fi~IRFACE:
Road
I-I~e NO.
/~a 271'
4 x 4' Bell Hole
PINE NECK RD