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HomeMy WebLinkAbout1905 Fairway DrDate: 04/12/05 Town Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Receipt#: 4807 Transaction(s): 1 Permits Reference Subtotal 379 $170.00 Check#: 4807 Total Paid: $170.00 Name: Keyspan, Energy - Gas Cont Dept 175 E Old County Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 379 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£#T100480084 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) 1905 Fairway Drive, Cutchogue Name of Owner of Premises Address 3) Fairway Drive - 4'X4' hellhole on the e/s of Fairway Drive~ 600' n/o Green Way~ for a gas service to 01905 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~dle's License No. //] ~J Sign~iire o f Al~lic~nt ' ~/ 04-05-05 Date 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 ora 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: $ 11) Remarks: , Lot Completion Date D-39 Pagelof3 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) b) T100480084 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 applications and permits: Basic Application Fee Al. I /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.fi = $10.00 - 1.f. ~ $0.10 = Additional Excavations 18" in depth to 5' in depth: 0-100 1.f. = Additional 1£ ~ .30 = D. Excavations 5' in depth and over: 0-100 I.f. = $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 the Town Clerk of the Town of Southold ~o issue a Highway Excavation Permit to: KEYSPAN ENERGY I)ELIVERY in accordance w/th this application. Received by the Town Clerk q~ ]/-0 ~ Permit Issued g~--/o~ -/9 ~-' Date Permit No. · 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 1~t 2~d 4th 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 Construction WIP - 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 ~ PF_Ih-VIIT APPLICATION SKETCH DATE: LOCATION: TOWN: WORK ORDER: 4t5~2~05 11:18:36 AM 1905 FKIRWAY DR CUTCHC(3UE T100480~4 ~TLLAGE ©P CI~OSS STREET: GREFA',I WAY /~JRFACE: 1V~ 1%ad H~e NO. 1905 4 x 4' Bell Hol~ 21006' FAIRWAY DR .. N