HomeMy WebLinkAbout280 Fairway DrDate: 02/22/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
4561
Transaction(s):
1 1 Permits
Check#~4'~'
Reference
371
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: 371
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#T100466036
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 Tvue
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant
2) 280 Fairway Drive, Cutchogue
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
Address
Address
Fairway Drive -bellhole n/s of Fairway Drive~ 290' w/o Cases Lane~ Cutcho~ue, to install oas
service to house #280
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 Trade~s~License No.
f/' /Sign at ur e o f~pp~a~t
/ / 02- 6-0s-
x,/ Date
5) a) At~ach plat 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) At~ach all other necessary permits and licenses for this projecL
c) Work covered by this application may not commence before issuance of a Highway Excavation Permit
by the Town Clergo
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 of 3
T100466036
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 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.f. = $10.00 -
1.f. @ $0.10 -
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f. =
Additional if. @ .30 =
D. Excavations 5' in depth and over:
0-100 l.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 t~ issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance w/th this application.
Received by the Town Clerk '3'7-' // °0/
Permit Issued ~/.~ .~/O Ctt Date Permit No,
SUP~.I~N~NDENT OF HIGHWAYS
Peter W. Harri~
I ~te
7/
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 inspechon,
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Ist
3rd
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
W[P - 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
~ PERM/T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
2516f2{]05
280 FAIRWAY DR
CUTCHOGUE
T100466~36
VILLAGE OF
CROSS STREET: CASES LN
~URFACE:
M~c~l,,m P~d
Houm N(~
4 x 4' Bell Hole
Z
FAIRWAY D R