HomeMy WebLinkAbout675 E Legion AveTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/18/04
Transaction(s):
1 Permits
Receipt#:
4011
Subtotal
$45.00
Check#: 4011
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC InternallD:101295
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#T100432633
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 lo 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) 675 E. Leeion Avenue, Mattituck
Name of Owner of Premises
Address
3) E. Legion Avenue - bellhole s/s Legion Avenue~ 100' w/o N. Riley Avenue, Mattituck, to install a gas service
to #675
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 ~e's License No~.._
f] / Signature of ~l~pl~ant
5) 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 projecL
c) Work covered by this application maynotcommencebeforeissuanceofaHighwayExcavationPermit
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 I of 3
T100432633
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 aoolications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. ~/Additional Excavations same service ~ $10.00 =
No.
$25.00
B. Excavations 18" in depth or less:
0-100 I.E = $10.00
l.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
Lf. @ $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 w/th this application.
Received by the Town Clerk
Permit Issued /~'~ ~/O ~ Date Permit No.
· ' ' Peter W. H~rris
! Dato
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
~ PERMIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
10il ~'2D04 ?:47:34 AM
oW.5 E LEGION AVE
MATIXT[JCK
TI00432~3
VILLAGE OF
CROS~ SrREET: N RILEY AVE
~/~tFACE:
Macadam
NO.
I00' ~
,~ x 4' Bell Hole
E LEGION AVE
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1~t
2nd
3rd
Findings (use code)
Applicant Notified
(To Permit Clerk)
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- lnspectorholding for final settlement ofexcavafion
RFR- Ready to Repair
D-39 Page 3 of 3