HomeMy WebLinkAbout3850 Stillwater Ave ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
KECOKDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
FAX TRANSMITTAL
To:
From:
Dated:
Re:
Janet - Keyspan (516-545-4474)
Linda J. Cooper, Deputy Town Clerk
January 21, 2005
Permit for Stillwater Ave
Number of Pages (including cover):
If total transmittal is not received, please call 631-765-1800.
COMMENTS:
As you requested
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/20/05
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt#: 4460
ference ~ Subtotal
$186.00
Check#: 4460
Total Paid: $186.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 368
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11950
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100456537
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
2) 3850 Stillwater Avenue, Cutchogue
Name of Owner of Premises
3)
Address
Address
Sflllwater Avenue - bellhole and a 120' trench in the n/e grass area n/o Track Avenue~
Cutchogue~ to install gas main and a gas service
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal 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 Tr~ (~ ~"~~'
t Sign~ure of Al~plica~ ~ ~ 01-11-05
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 of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section ., Block , Lot
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:
Completion Date
D-39 Page I of 3
T100456537
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $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 -
l.fi ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 $30.00
20 l.f. ~ .30 = $6.00 $ 6.00
Additional
D. Excavations 5' in depth and over:
0-100 1.f. = $50.00
I.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 = $186.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit
KEYSPAN ENERGY DELIVERY in accordance w~th this application.
SUP~'~NT OF HIGHW/AYS
Permit Issued / - ~O -d9-9j Date Permit No.
Peter W. Harris
Not~e: Permit expires one ( 1 ) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Penmt must be available for inspection.
D-39 Page 2 of 3
Cow Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
yd
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
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
13~50
PERM~
HO.
LOOA~ON
REASON FOR
OPENING
W,OJPA
NO.
REQUESTED
BY
KEYSPAN GAS CONSTR 631 758 5136
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
MI6 ~0 DA~
FOREMANi DATEOF
. . O~N
, DEPA~ME~ · DIVISION
~S ~NSTR, MAINT. & SERVICES
P. 04