HomeMy WebLinkAbout1060 Sigsbee RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/20/04
Transaction(s):
Permits
Receipt~:
3818
Subtotal
$45.00
Check#: 3818
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 100644
PermitNo. ~ , t~(T
Fi,eNo.
TOWN OF SOUTHOLD
tHGI-I~VAY DEPARTMENT
Peconie Lane
Peconie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100423326
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 Soutbeld, 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 oftbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant Address
2) 1060 Slesbee Road` Matlituck
Name of Owner of Premises
Addr~s
3)
Si~sbee Road - bellhole w/s oaved area aoorox. 1110' s/o the Main Road. Mattfituck- for a eas service to
1060 Sigsbee Road
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.
No X
4) Builder's License No.
Electrician's License No.
Plumber's License No.
Other T~'s License No.
~tur! ~
(~ 09~;'~e4
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremlses~r
public streets or areas, and giving a detailed description of layout of excavation.
b) At'tach 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~9
Pagelof3
T100423326
12) lnsuranceCoverage: (Attach Copy)
a) Insurance Company:
b) Policy g
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 anvlications and oermits: 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
l.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 Lf. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-I00 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 h~reby 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- ~
Date
Permit Issued ~' t2.~' ~ ~ Permit No.
SUPERINT.-Fa~DENT OF HIGHWAYS
TO N. WT
· eter ~. Harris'
Note: Pcrmit expires one (l) year from Date of lssuance. Noworktostartwithout48hournoticetotheSuperintondentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
10:54 KEYSPAN GAS CONSTR 651 958 5156 P.02
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
~--~ STATE ~ NASSAU SUFFOLK
oOU.TY ~ OOU.TY ~ ~o~
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W.O.IPA
NO,
REQUESTED
BY
APPROVED
SKETCH
MIS dOB -- DATE ~/~/~.¢~ O ~
DATE
N
Cow Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3rd
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
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3