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HomeMy WebLinkAbout37 Wilmarth AveDate: 04/20/05 Town Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Receipt#: 4828 Transaction(s): 1 Permits Reference Check#: 4828 Total Paid: Subtotal $170.00 $170.00 Name: Keyspan, Energy - Gas Cont Dept 175 E Old County Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 381 Permit No. Eile No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958 (631) 765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Re£#T100479557 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 sit~ Print or Type 1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVH J~E_ NY I 1801 Name of Applicant Address 2) 37 Wilmarth Avenue, Greenport Name of Owner of Premises Address Wilmarth Avenue - n/s of Wilmarth Avenue~ 205' e/o Booth Place, Greenport for a gas lealt repair at #37 4) Work Description and Location (Street Number, Hamlet, Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes, other Town permits may be required. 4) Builder's License No. Plumber's License No. s) Electrician's License No. ' Signat~ of A~pli~nt t/ 04-08-05 Date a) Attach plot plan showing location of propesed excavation and relationship to adjoining premis~ 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) ~~rk c~vered by this app~icati~n may n~t c~mmenee bef~re issuance ~f a Highway Excavati~n Permit by the Town Clerk. 6) Tax Map: Section , Block 7) Starting Date: Completion Date: 8) 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 Propased Work: $ 11) Remarks: D-39 Pagelof3 T100479557 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 ors b) Maintenance Bonded provided: 2 years or 3 years 14) Fees for anDlications 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 I.fi: $10.00 - l.f. @ $O. lO - Additional Excavations 18" in depth to 5' in depth: 0-100 I.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 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 with this application. Received by the T~7 Clerk Permit Issued Date Permit No. -~ YV SUPEPdN~T~DENT OF HIGHWAYS Peter W. Harris Date Not~e: 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 1st 3rd Findings(usecode) 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 Construction W[P - Work in Progress DB - Improper backfill (too high) (not sufficient) HFS- Inspector holding for finalsenlementofexcavation RFR Ready to Repair D-39 Page 3 of 3 KEYSPAN REQUEST FOR STREETOPENING PERMIT DEPRRmENT I Ol'~mlON ~.. I07-q~ N ?L.