HomeMy WebLinkAbout3980 Wickham AveTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/13/04
Transaction(s):
1 Permits
Receipt#:
4342
Subtotal
$45,OO
Check#: 4342
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 102283
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£#T100449226
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 neeessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11001
Name of Applicant Address
2) 3980 Wickham Avenue, Mattituck
Name of Owner of Premises
Addr~s
3) Wickham Avenue - bellhole s/s of Wickham Avenue, s/w i/o Marys Road and Wickham Avenue~
Mattituek, to install a gas service to #3980
4) Work Description and Location (Street Numl~r, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes No
*lf yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
s)
Electrician's License No. Other Trades License No.
/
~ ~ignat)tlcfi~f ~ppI~~/ant
L/12-08-04
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.
¢) 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 .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39 Page I of 3
T100449226
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #~
c) State whether policy of certification on file with the Highway Depamn~t:
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 ~ermits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 = $20.00
$25.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.fi = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional Iff @ .30 =
D. Excavations 5' in depth and over:
0-1001.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 = $45.00
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.
SUP~-~ENT OF HIGHW~6jI~S
Peter W. Harris
Date t
Received by the Town Clerk / ~ -- / ~ r ~ ~
Date
Permit Issued /,~ ~/~ ' 6~ ~ PermitNo.
Note: Pc~cmit expires one (l) year from Date of Issuance. No work to start without 48 hour notice to the 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
4*h
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
WlP Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ PF. RM~T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
7;2/2093
3~0 WICIC-IAM RD
GARDEN' CITY
T100449226
VILLA GE OF
CROSS//IF,.EET: MARYS RD
MJRFACE:
Macadam Road
3980
,~ x 4' l~ell Hole
WICKHAM RD