HomeMy WebLinkAbout40 Sutton PlTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 11/17/04
Transaction(s):
1 Permits
Receipt#:
4188
Subtotal
$82.50
Check#: 4188
Total Paid:
$82.50
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 101787
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#T100439412
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southolcl 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) 50 Sutton Place. Greennort
Name of Owner of Premises
Address
3) Sutton Place - bellhole in the i/o Sound Road and a 125' trench in the n/s grass area of Sutton Place~
Greenoort~ to install a gas main and gas service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
No X
Plumber's License No.
Other ~ra~e's License
5) a) At~ach 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) At~ach 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 , 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 1 of 3
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:
13) Security:
a)
b)
T100439412
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee ................. $25.00
Al. I /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. ~/Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
l.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00 = $30.00
25 I.f. ~ $0.30 -- $7.50
Additional
D. Excavations 5' in depth and over:
0-1001.~ = $50.00
1.f. ~ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations @ $I0.00 = $
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 $82.50
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.
Received by the Town Clerk //-/7- ~) ct/
Date
Permit Issued J/~/ 7) ~.0O- Permit No..~--J~_~J
SUP EJ~lq'~'l~ ENT OF HIGHWAYS
Note: Permit expires one (1) 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
0?:38
KEYSPAN GAS CONSTR 631 ?58 5136
APPROVED
~KE'rCH
DEPARTMENT JDIVISION
GA,~ CONETR, MAINT, & 8ERVI~DEE
IOATE
P. 02
TOTAL P.02
Copy Distribution:
Highway Depanment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2ha
Findings(usecode)
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
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final set~lement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3