HomeMy WebLinkAbout330 Summit LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/08/05
* * * RECEIPT * * *
Receipt~: 5031
Transaction(s):
1 1
Permits
Reference Subtotal
390 $170.00
Check#: 5031
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 390
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
ReL#T100491086
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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILI.E_ NY 11801
Name of Applicant Address
2) 330 Summit Lane, East Marion
Name of Owner of Premises Address
Summit Lane - belihole e/s grass area~ approx. 350' s/e of Marina Lane~ for a gas service
installation
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) is construction located within 75 feet of tidal wefiands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
X
s)
Electrician's License No.
Hate
a) Attaxhpl~tplansh~wingl~eati~n~fpr~p~sed~xcavati~nandrelati~nshipt~adj~iningpremises~r
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 ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of 3
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:
13) Security:
a)
h)
T100491086
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications 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 -
I.f. ~ $0.10 --
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional 1£ ~ .30 =
Excavations 5' in depth and over:
0-1001.f. = $50.00
l.fi @ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations @ $I0.00 = $
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 gran~d to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUP.~-'~INDENT OF HIGHWAYS
Peter W. Harris
Date
Permit No.
Received by the Town Clerk
Permit Issued ~- ~'~O~.~
Note: Permit expircs one (1) year from Date oflssuance. Noworktostartw/thout48hournoticetotheSuperintendcntofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Depa~ment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1~t
2.d
Findings (use code)
Applicant Notified
(To PermitClerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken t~ench or excavation
UTM - Unable m measure (due to backfilling)
BUC - Building under Construction
WlP - 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
KE.~i~PAN GAS CONSTR 631 ?58 5136
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
~-'~ STATE ~ NASSAU SUFFOLK
/
FOREMAN
DATE OF
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
DATE
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO,
REQUESTED
BY
APPROVED
SKETCH
TOTAL P. 04