HomeMy WebLinkAbout1400 Sound DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/20/05
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt#: 4459
~enc~ Subtotal
36~,/ $170.00
Check#: 4459
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: UNDAC Internal iD: 367
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#T100457066
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South#Id for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South#Id, 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) 1400 Sound Drive, Greenport
Name of Owner of Premises
4)
Address
Address
Sound Drive - bellhole n/s grass area approx. 75' e/o Inlet Pond Road~ Greenport, to install gas
service to house 01400
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.
4) Builder's License No.
Electrician's License No.
5)
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:
Signature of Applicant
01-12-05
Date
a) Atlach plot plan showing location of pr#posed 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:
Completion Date
D-39 Page 1 of 3
T100457066
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 lnjury, 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__/Sarvice Connections excavations ~ $20.00 = $20.00
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-1001.fi $10.00-
I.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional It ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $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
penmt.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPER~NDENT OF HIGHWAYS
TO,lq OF~S~)UTHgLD, NEV//~OmC
Pet~ W. Harris
Received by the Town Clerk v/- / ~ ~Off"
pate
Permit Issued / 'tagO -- O.~ Permit No.
Not__e: Permit expiresone (l)year fromDate of Issuance. No workto start without 48 hournotice tothe Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Depanment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2ha
3ra
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
IL - Improper lights
ST Sunken trench or excavation
UTM Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
JA~-10-2005 13:25
~---~STATE
KEYSPRN GAS CONSTE 631 75~ 51~
KEYSPAN
REQUEST FOR STREET OPENING pERMIT
J----] NASSAU SUFFOLK
COUNTY [w~ COUNTY
P. 0~
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
FOREMAN
SKETCH
DEPARTMENT
GAS CONSTR. MAINT,&$ERVICES
DATE OF
OPENNG
DIVISION
DATE
N