HomeMy WebLinkAbout1680 Lands End RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/27/04
Transaction(s):
1 Permits
Receipt#:
3695
Subtotal
$55.00
Check#: 3695
Total Paid:
$55.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Intemal ID: 99989
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100416934
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 ~ 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. - HICKSVILLE~ NY 11801
Name of Applicant
2) 1680 Lands End Road, Orient
Name of Owner of Premises
3)
Address
Address
Lands End Road - bellhole w/s Rrass area and a test hole e/s uaved area anorox. 90' s/o Latham Lane~
Orient. to install a gas service to #1680
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.
4) Builder's License No.
Electrician's License No.
s)
No X
Plumber's License No.
Signatur~ of.~ppl~a~t
08-20-04
Date
a) Attach plot plan showing location of proposed excavailon and relationship to adjoining premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all other neeessar)' 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
7) Starting Date:
8) Work Schedule:
· Block , Lot
Completion Date:
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-39
Page I of 3
T100416934
12) Insurance Covemac: (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
Al.I /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. 1 /Additional Excavations same service ~ $10.00 = $10.00
No.
$25.00
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00
1.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 =
__ l.f. @ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
1.£ @ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $i0.00 = $
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 $55.00
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 appbcahon.
Received by the Town Clerk ~/Da~ O c'/
Permit Issued 4o~'~/~ ~ Permit No.
SUPERIN]2F. IalIPENT OF HIGHWAYS
Tow O* S T.O p, NEWy3Z
- ~ Veie~.~s -
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 Page2of3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO,
LOCATION
REASON FOR
,OPENING
W, OJPA
NO,
REQUESTED
BY
APPROVED
STATE ~-~ NASSAU SUFFOLK
cou.TY COU.TY
GAS CONSTR. MAINT. & SERVICES
SKETCH
DATE
d~~ 126
SO'd
~£SN03 S~D N~S~B~
N
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3~
4~
Findings (usc code)
Applicant Notified
(To PermitClerk)
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- Inspectorholdingforfinalsettlemantofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3