HomeMy WebLinkAbout2625 Jackson StTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/03/04
Transaction(s):
1 Permits
Receipt#:
4235
Subtotal
$45.00
Check#: 4235
Total Paid:
$45,00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 102044
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#T100442136
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 Address
2) Jackson Street, New Suffolk
Name of Owner of Premises
3)
Addr~s
Jackson Street- bellholes/s approx. 45'e/oSecond Street~toinstalla gasservicein New Suffolk
at#2625
4) 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.
4) Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other Tr~6'~s License No.
/] I Signature o~Apl~cant
~/ 11-17-04
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.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Propased Work: $
11) Remarks:
Lot
Completion Date
D-39 Pagel of 3
T100442136
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 l.f. - $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.£ =
Additional lf. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.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.
SUP~ih~JNDENT OF HIGH/WAYS
TOj6/N OF~UT~LD,., $~l~ YORK
' - Peter W. [I~[rris
Date
Received by the Town Clerk /c~ ~ "Or/r
Permit Issued /~ ~'O ~ Date Permit No.
Note: Permit expires one ( 1 ) year from Date of issuance. No work to start ~vithout 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
Findings (use code)
Applicant Notified
(To Permit Clerk)
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 -lmproper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
07:2~
KEYSPAN GAS CONSTR
K£YSPAN
REQUEST FOR STREET OPENING PERMIT
6El 758 5156 P.OJ
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W.O./PA
F--~STATE F--] NASSAU SUFFOLK
COUNTY [~ COUNTY
DATE
NO.
REQUESTED
BY
APPROVED
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
SKETCH
DIVISION
DATE
N