HomeMy WebLinkAbout350 Oak RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/20/04
Transaction(s):
1 Permits
Receipt#:
3814
Subtotal
$45.00
Check#: 3814
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC In~rnallD:100643
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100422780
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 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. - HICKSVH,L~_ NY 11801
Name of Applicant
2) 350 Oak Road. New Suffolk
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
Address
Address
Oak Road - 4'X4' bellhole on the s/s Oak Road, 280' w/o New Suffolk Road. New Suffolk for a gas service
to 350 Oak Road
Work Description and Location (Street Number, Hamlet, Cross Stree0
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trad~License No.
~ignature of ~ppli~n{
Date
a) Attachp~~tplansh~wi~g~~cati~n~fpr~p~sedexcavati~nandre~aB~nshipt~adj~iningpremises~r
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all other n~essary 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
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:
, Lot
Completion Date
D~9
Pagelof3
T100422780
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
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and vermits: Basic Application Fee ................. $25.00
Al. 1 /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. = $I0.00
1.f. @ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.E. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 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 hereby granted to the Town Clerk of the Town of Southold m issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPE~T OF HIGHW/AYS
Received by the Town Clerk ~/D~a5?O ~'
Permit Issued gfi/~/~-ff Permit No.
Peter W. Harris
/ D~te /
Note: P~rmit 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:
9510f2~3
350 OAK RD
blEW SUFFOLK
T100422'~0
VILLAGE OF
(~OS~ ~fREET: NEW SUFFOLK RD
~[1RFACE:
IHe~Ie NO.
,~ x 4' Bell Hole
OAK RD
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1~t
2nd
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
1L - 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- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3