HomeMy WebLinkAbout565 Gull Pond LnDate: 03/11/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 4615
Transaction(s):
1 1
Permits
Reference Subtotal
373 $17O.0O
Check#: 4615
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 373
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100466844
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
Name of Applicant Address
2) 565 Gull Pond Lane, Greenport
Name of Owner of Premises
Addr~s
Gull Pond Lane - bellhole on w/s of Gull Pond Lane, 750' s/o Route 48 (Hwy. 25) to install gas
service to house #565
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tldal wetlands? *Yes No __X __
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No. Other Tra~f~License No. ~
J/ ~Sign~t~reofnp, l~ca~ ~ -
~// k/ 02-18-05
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.
6) Tax Map: Section , Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
Il) Remarks:
D-39 Page 1 of 3
T100466844
12) Insurance Coverage: (Artach 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
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: Basic Application Fee
Al. _l__/Servicc 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.f. = $10.00-
1.f. @ S0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional Iff ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.£ = $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 atiached 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 m issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this applicat/on.
SUPE~t'Iq~NDENT OF HIGHWAYS
· or/souv} i>, e /Yomc
- Pc r W Harri,~s. - ~.t
Received by the Tom Clerk ~ / 7~)~ t D~te
Pe~it Issued ~/il/0,¢ te Pe~it No. ~ D
Not~: Pemit expires one (1) year from Date of Issuance. No work to s~ ~thout 48 hour notice to the Sup~ntend~t of Highways.
P~it must be available for insp~fion.
D-39 Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
2~a
3~
4th
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 - Workin Progress
DB - lmproperbackfill (too high) (not sufficient)
HFS- Inspector holding for finalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
2fl~f2~5 11:32:22 AM
GULL POND LN
GREEi~OP.T
T100466?Z~4
VILLAGE OF
Cl~Ogg SrREET: ROUTE 48
SURFACE:
M~cadam P~ad
He'~e NO.
565
4 x 4' Bell Hole
GULL POND LN
N ~