HomeMy WebLinkAbout420 Depot LnTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/03/04
Transaction(s):
1 Permits
Receipt:
4278
Subtotal
$45.00
Check#: 4278
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 102042
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100445270
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) 420 Depot Lane, Cutchogue
Name of Owner of Premises
4)
4) Builder's License No.
Electrician's License No.
$)
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authorily is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Address
Address
Depot Lane - bellhole w/s of Depot Lane, 243' s/o School Rouse Lane~ Cutchogue~ for a gas
service installation to 0420. THIS IS A RUSH INSTALLATION.
Work Description and Location (Street Number, Hamlel, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X__
*If yes, other Town permitn may be required.
Plumber's License No.
// ] .~ Signat~/~ofAppli~nt ff ~
~/L/I 1-24-04 --
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:
Comuletion Date
D-39 Pagelof3
T100445270
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with thc 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
ors
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.fi ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional If. @ .30 -
D. Excavations 5' in depth and over:
0-100 l.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
permit.
TOTAL COST = $45.00
Authorization is hereby granted to the Town Cl~rk of the Town of Southold to issue a Highway Excavation Pezmit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPE~LT~NDENT OF HIGHWAYS
Peter W. Harris
Date
Received by the Town Clerk /o~ - ~ - ~ ff~'
Date
Permit Issued /~:~ -~- O ~ Permit No.
Note: Permit expires one (l) year from Date oflssuance. Noworktostartwithout48hournoticetotheSuperintend~ntofHighways.
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
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
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficien0
HFS- lnspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ P~T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
111'2,4/2004 l~:,36:1 -~ AA4
420 DEPOT LN
CUTCHOGUE
T10044._~270
VILLAGE OF
CROSS srP, EET: SCHOOL HOUSE L.N
f~RFACE:
Macadam Road
l-I.~e NO.
420
243'
4 x 4' BellHole
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DEPOT LN