HomeMy WebLinkAbout2145 Oaklawn AveDate: 01/13/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt"8: 4430
Transaction(s):
1 1
Permits
Reference Subtotal
366 $45.00
Check#: 4430
Total Paid: $45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 366
Per, mit No.'
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100454251
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 oftbe
job site~
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant
2) 2145 Oaklawn Avenue, Southold
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
Oaklawn Avenue - hellhole e/s grass area approx. 485' s/o Jernick Lane, Southold~ to install a
gas service to #2145
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 Tra~ t~en~e N~o.
~Signat~e of App~can~'~ --
01~e4
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 n~cessary 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
I)-39 Page ! of 3
T100454251
12) Insurance Coverage: (AHach 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 annlications and oermits: Basic Application Fee Al. I /Service Conncctians cxcavatians ~ $20.00 = $20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-1001.fi $10.00-
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional lf. ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
l.f. ~ $0.50 = $_
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $.
Notice to public utilities proof must be provided and attached to this application prior to issuance of
peimit.
· · · 17 9-..
TOTAL COST =$~S.0O [~/d,9~,~'~'~'.~/
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.
Received by the Town Clerk
Date
Permit Issued /~/Lt/~ ~- Permit No.
SUPERINTENDENT OF HIGHWAYS
TOWN/Ef~JTHOLD, NEW Y~)RK
Peter W. Hams
Note: permit expires one (1)year from Dateoflssuance. Nowork to start without 48 hournoticetothe Superintendent of Highways.
permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
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 - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
['-~STATE
NASSAU SUFFOLK
COUNTY ~ COUNTY
PERMIT
NO,
LOCATION
REASON FOR
OPENING
MIS
,o. J°~-7~,-/~4~. ~- /
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
FOREMAN
DEP~;RTMENT
GAS CONSTR. MAINT, & SERVICES
DATE OF
oPE..Q
DIVISION
. DATE
N
Date: 01/24/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 44844463
Transaction(s):
3 3
Permits
Reference Subtotal
~,365,366 $375.00
Check#: 4484/4463
Total Paid: $375.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E QId County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internai ID: 364,365,366