HomeMy WebLinkAbout245 Cindy LnTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/26/04
Transaction(s):
1 Permits
Receipt#:
0
Subtotal
$45.00
Cash
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 101462
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100444080
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, oedinanc~s 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) 245 Cindy Lane. Mattituck
Name of Owner of Premises
Address
3) Cindy Lane - bellhole w/s Cindy Lane~ missiling over to e/s, 242' s/o Deer Drive~ Mattituck~ to install a gas
service to #245
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*lf yes, other Town permits may be required.
No X
4) Builder's License No.
Electrician's License No.
s)
Plumber's License No.
Other Tr~ License No.
J/ ~Signature o f~_ppli~/nt~
a) Aaach plot plan showing location of propesed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description of layout of exeavation.
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 ~ 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
Pagelof3
T100434080
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depamnent:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 properly 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 ................. $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 l.fi $10.00
I.~ ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.fi ~ $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 m:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SU)~ENT OF HIGHW~,YS
Peter W. Harris
Date /
Received by the Town Clerk
Permit issued J/~a,~et~O ,r_~· ' Date--Permit No'
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.
9-39 Page 2 of 3
~ PF, RMIT APPLICATION SKETCH
DATE:
LOCATI ON:
TOWN:
WORK OP, I)ER:
10.q8~004 10:52:03 A.M
2,45 CINDY LN
MATTITUCK
T100434~0
VILLAGE OF
CROSS SrREET: DEER DR
S[]RFACE:
Ho~e NO.
342'
4 x 4' BellHola
CINDY LN
N ~
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
ist
2~
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
1L - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Workin Progress
DB Improper backfill (too high) (not sufficient)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3