HomeMy WebLinkAbout440 Pine Neck RdOsTOWn Of Southold
P.O Box 1179
outhold, NY 11971
* * * RECEIPT * * *
Date: 12/07/04
Transaction(s):
Permits
Receipt~:
4305
Subtotal
$45.OO
Check#: 4305
Total Paid:
$45.00
Name:
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 102125
~ermit 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#TI00447468
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) 440 Pine Neck Road, Southold
Name of Owner of Premises
3)
4)
4) Builder's License No.
Electrician's License No.
Address
Address
Pine Neck Road - bellhole s/s of Pine Neck Road~ 430' e/o Main Ba~view Road, Southold, to
install a gas service to 0440
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.
Plumber's License No.
Other Trade's License No.
$)
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
12-01-04
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 thc Town Clerk.
., Block , Lot
Completion Date:
Completion Date
D-39 Page 1 of 3
T100447468
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. _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 hf. = $10.00 -
l.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional Iff @ .30 =
D. Excavations 5' in depth and over:
0-100 1.fi = $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
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.
SUPE~qTI~DENT OF HIGHWAYS
terW.
Received by the Town Clerk /~/7/~ ~ /ate -/
me~it Issued fi a~ memit No.
No~: Pe~it expires one (1) year from Date of Issuance. No work to sta~ without 48 hour notice to the Superintendent of Highways.
P~it must be available for insp~tion.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
2nd
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
DATE:
LOCATION:
TOWN:
WORK ORDER:
12/1/2004 1:16:32 PM
440 PIhTE NEC;K RD
$OUTHOLD
T100447468
PERMIT APPLICATION SKETCH
VILLAGE OF
CROSS SrREET: MAIN BAYVIEW RD
~URFACE:
Macadara l~ad
Home NO.
430'
Bell Hole
PINE NECK RD