HomeMy WebLinkAbout2515 Hobart RdDate: 04/29/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
4896
Transaction(s):
1 1
Permits
Reference
386
Subtotal
$170.00
Check#: 4896
Total Paid:
$170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 386
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£#T100484546
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
4) Builder's License No.
Electrician's License No.
Name of Applicant Address
2) 2515 Hobart Road, Southold
Name of Owner of Premises Address
Hobart Road - bellhole n/s, 100' w/o Old Shipyard Lanen to install a gas service to house #2515
4) 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.
Plumber's License No.
Other Tr~'_s License No.(~ ~-
! Sig ureof~l~plic t -
~/~ '~ 04.25_05~ [
Date
5) a) Attach plot plan showing loeation of proposed 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 eommence before issuance of a Highway Exeavafion Permit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Bacldill & 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
T100484546
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 aoolications 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 1.f. = $10.00 -
I.L @ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.1~ =
Additional Iff ~ .30 =
D. Excavations 5' in depth and over:
0-100 Lfi = $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 thc Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit lssued ~7//a~ ~'/D.~- Date Permit No,
SUPERINTENDENT OF HIGHWAYS
TOgq'hOg'g~trmgLD, NE ~V/VOPd<
Peter~W. h'*a r~ri;
Note: Permit expires one ( I ) 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
CODY 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
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 sufficien0
HFS- Inspector holding for finalsettlementofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
~ PF~RMIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
zl/25/2005 1:26:~ PM
2515 HOBART RD
SOUTHOLD
T100~43z16
VILLAGE OF
CROSS STREET: OLD SHIPYARD LN
~JRFACE:
Macadam Ro~d
Home NO.
2515
100'
Bell Hole
z
HOBART RD