HomeMy WebLinkAbout800 Horton LnTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/14/04
Transaction(s):
1 Permits
Receipt#:
3738
Subtotal
$45.00
Check#: 3738
Total Paid:
$45.00
Name:
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 100477
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHYVAY EXCAVATION AND REPAIR
ReL#T100415625
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 ~gulations 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 sit~
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE_ NY 11801
Name of Applicant Address
2) 800 Horton Lane~ Southold
Name of Owner of Premises
Address
3)
Horton Lane - 4'X4' bellhole in the e/s erass area. 100' n/o Sunnyside Road~ Southold~ for a gas retirement
to 800 Horton Lane
Work Description and Location (Street Number, Hamlet, Cress Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
4) Builder's License No.
El~trieinn's License No.
No X
*If yes, other Town permits may be required.
Plumber's License No.
u Signature~
°a~;t'°e4
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 uther 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-39
Page I of 3
T100415625
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of cextification 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) SecuriW:
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. 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 I.f. = $10.00
1.£ @ $o. io = $
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f. = $30.00 --
~ 1.f. ~ $0.30 =
Additional
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 atlached to this application prior to issuance of
permit.
TOTAL COST $45.00
Received by the Town Clerk
Date
Permit Issued ~~ /Y--/- 1~9 {1/ Permit No.
Authorization is hereby granted to the Toven Clerk of the Town of Southold to issue a Highway Excavation Pertmt to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
)DENTOF.IO.W YS
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:
WOP, K ORDER:
8;'27;'2004 11:03:43 ~
~00 HORTON LN
$OUTHOLD
T100413623
VILLAGE O:F
(~OSS STREET: 5UNNYSIDE RD
6~RFACE:
Or~D~
NO.
~0
,4 x 4' Bell Hole
100' ~
HORTONLN
Cow Distribution:
HighwayDepartment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
ist
2~
3ra
Findings(usecode)
Applicant Notified
(To permat 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
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for finalsettlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3