HomeMy WebLinkAbout1425 Gull Pond LnTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/20/04
Transaction(s):
1 Permits
Receipt#:
3813
Subtotal
$45.00
Check#: 3813
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 100642
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
Ref.#T100423179
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 oftke
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant
2) 1425 Gull Pond Lane. Greenport
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
6) Tax Map: Section
7) Starting 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:
Address
Address
Gull Pond Lane - 4'X4' bellhole on the w/s Gull Pond Lane~ 1500' s/o North Road~ Grecnport~ for a gas
service to 1425 Gull Pond Lane
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is eonstruction Ioeated within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
Plumber's License No.
Other T~'s License No.
// / v Signatur~'of A~li~ant
09-10-04
Date
a) At~ach plot plan showing location of proposed excavation and relationship in 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.
, Block , Lot
Completion Date:
Completion Date
D~9
Pagelof3
T100423179
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certificatinn 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) Secuhty:
a)
Surety Bond or Certified Check provided in the total amount
nfS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aonlications and permits: 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:
0-1001.£ = $10.00
1.£ @ $0.10= $
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
Excavations 5' in depth and over:
0-100 l.fi = $50.00
1.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
Received by the Town Clerk ~/7/'~ ~
Permit Issued ~/2 0A a/~ Date Permit No.
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 applicahon.
SUPE~ENT OF HIOH~W~fS
l~etet W. ~tams
Note: Pemait 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
DATE:
LOCATION:
TOWN:
WOP, K ORDER:
9510/211)3
1425 G~_L POND LN
OREENPOt~T
T100~23179
P~T APPLICATION SKETCH
VILLAGE OF
(IROSS STREET; NORTH RD
~JRFACE:
Mac.bra Road
Home NO.
IX)O'
~ x 4' Bell Hole
DULL POND LN
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Pen'nit 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- lnspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3