HomeMy WebLinkAbout9900 Sound AvePermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100428977
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 uther
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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSV1LLE, NY 11801
Name of Applicant Address
2) 9900 Sound Avenue, Mattituck
Name of Owner of Premises Address
3) Sound Avenue - bellhole s/s Sound Avenue~ 500' w/o Factory Avenue. Mattitucl~ for a cas service to 09900
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __X __
*lf yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
Electrician's License No. Other Tr~'s License No..
/ IX F Sign~re~fA~(plic~t'
~ - 10-04-04
Date
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 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 .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
D~9
Pagelof3
T100428940
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 ................. $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.f. = $10.00
I.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
Excavations 5' in depth and over:
0-100 1.f. = $50.00
I.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.
SUPERINTE~..~L~ENT OF HIGHWAYS
v -- - Peter~/.Ha?ris
Receiv~ by the To~ Clerk
Note: Pe~it expi~s one (I) year from Date of Issuance. No work to s~ without 48 hour notice to the Sup~nt~dent of Highways.
Pe~it must be available for insp~fion.
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)
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- lnspectorholding forfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SI~TCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
1054t2004 11:16:05 AiM
9900 SOUND AV
MAT~TUCK
T100428g'??
VILLAGE OF
CRO~ ~FREET: FACTORY AVE
ISLW. FACE:
0
I'-Ie'~e NO.
9900
4 x 4' Bell Hole
SOUND AV
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/14/04
Transaction(s):
Permits
Receipt#:
3941
Subtotal
$45.00
Check#: 3941 'T' lOC) q 2 7'7
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID.' LYNDAB Internal ID: 101252