HomeMy WebLinkAbout1800 Shipyard LnDate: 03/11/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
4626
Transaction(s):
1 1
Permits
Reference
374
Subtotal
$17.00
Check#: 4626
Total Paid:
$17.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 374
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£#TI00468097
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 T~pe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant
2) 1800 Shipyard Lane, East Marion
Name of Owner of Premises
3)
4)
4) Builder's License No.
Electrician's License No.
s)
6) Tax Map: Section
7) Starting 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:
Address
Address
Shipyard Lane - bellhole on Gus Drive, 350' w/o Shipyard Lanen East Marion for a gas service
installation at 1800 Shipyard Lane.
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 T~a~le s License No.
// // ~/ S/i~ture ol~Apl~ca~t
L~/ ~/ 0z-z3-0s
Date
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.
, Block , Lot
Completion Date:
Comnletion Date
D-39 Page 1 of 3
T100468097
12) Insurance Coveraee: (At~ach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of centification 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 I.f. = $10.00 -
I.f. @ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 1.1~ = $50.00
h£ @ $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.
SUPERINTENDENT OF HIGHWAYS
TO~ SOUTHOLD, ~ll~;g YORK
Permit lssued ~/{[/0~ Date Permit No.
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 inspechon.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
2na
3rd
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 -lmproper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
PERN~T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
2f23f200:
GUS DRIVE
EMAPJON
T10046~7
VILLAGE OP
5IREET: SHIPYARD LN
S~3RFACE: ~
1VIac~dam Ro~d ~
,4' Bell Hole
GUS DRIVE