HomeMy WebLinkAbout4390 New Suffolk RdDate: 03/11/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 4664
Transaction(s):
1 1
Permits
Reference Subtotal
375 $170,00
Check#: 4664
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 375
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#T100265761
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
lob site.
Print or Type
1) KEYSPAN ENERGY-GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLEq NY 11801
Name of Applicant
2) 4390 New Suffolk Road, New Suffolk
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
Address
Address
New Suffolk Road - 3'X~' hellhole on the w/s of New Suffolk Road~ 265' n/o Wicks Street, for a
gas leak repair at house #4390.
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 reqnired.
Plumber's License No.
Other Tr~s License No.
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 of a 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 Page 1 o1'3
T100265761
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certificafion 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) Secuhty:
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 I.£. = $10.00 -
hf. ~ $0.10 -
Additional
Excavations 18" in depth to 5' in depth:
0-100 1£ =
Additional lf. ~ .30 =
D. Excavations 5' in depth and over:
0-100 1£ = $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 Tow~ Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance xvith this application.
SUPERI~mE~ENT OF HIGHW~,AYS
TOVCI~OF~J~TH OI~D, N E~ORK
Received by the To~ Clerk
Note: Pe~it expires one (1) year from Date of Issuance, No work to sta~ without 48 hour notice to the Superint~dent of Highways.
Pe~it must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3~d
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- lnspectorholding for finalsettlementofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
APPROVED
KEYSPAN
REQUEST FOR STREET OPEN NG PERI~'rlT
FOR EMAI~I DATA OF
OAS CON S]'P.. M~INlr. & SERb ICES
N
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