HomeMy WebLinkAbout1460 Bray AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/13/05
* * * RECEIPT * * *
Receipt~: 4431
Transaction(s):
1 1
Permits
Reference Subtotal
365 $45.00
Check#:4431
Total Paid: $45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 365
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
Re£#T100455696
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 agree~ 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) 1460 Bray Avenue, Laurel
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
Bray Avenue - hellhole w/s of Bray Avenuen 105' s/o 4m Street, Laurel~ to install a gas service to
#1460
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 ~cenLN°%
[ Sign/~}~re ~f A~pli~t
~-/ 01-05-04
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.
., Block , Lot
Completion Date:
Comnletion Date
Pagelof3
T100455696
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 Jg2$'~F'
Al. _l~/Service Connections excavations ~ $20.00 = $20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
I.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi =
Additional If. @ .30 =
D. Excavations 5' in depth and over:
O-iO01.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.
* * *
Authorization is hereby granted to the Town Clerk of thc 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 J ~/t.,j --1:~ c~- Permit No.
SUPERINTENDENT OF HIGHWAYS
TOX~6'~OUTHOLD, NEW YORK
-,o v Pet¢r~.V. Hams
Note: permit expires one (1) year from Date of Issuance. No work to start w~thout 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Coov Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~
3ed
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
WlP - Work in Progress
DB - lmproperbackfill (too high) (not sufficient)
HFS- Inspector holding for final setllement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SI(]:TCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
15~00] 10:42:~9 AM
1~0 BRAY AVE
LAUREL
T100455~9~
VILLAGE OF
STREET: 4TH ST
${JRFACE:
Macadam Road
Hou~
1460
/ ~ 105"
4 x 4' B~ll Hol~
BRAY AVE
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 Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 364,365,366