HomeMy WebLinkAbout130 Cleaves Point RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/27/04
Transaction(s):
1 Permits
Receipt#:
3673
Subtotal
$85.00
Check#: 3673
Total Paid:
$85.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 99987
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
Re£#T100415888
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 Sout beld, 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 Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 130 Cleaves Point Road, East Marion
Name of Owner of Premises Addrtss
3) Cleaves Point Road - bellholes to missile under the road bed and a 78' trench in the s/s grass
4) Builder's License No.
Electrician's License No.
area at the i/o Gillette Drive~ East Marion~ to install a gas main and service to #130.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(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~Ps'~icense No.
/ / ~Signature of~ppli~m~
~/ / 8-17-04
~ Date
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) At~ach 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
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 t of 3
T100415888
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and oermits: Basic Application Fee ................. $25.00
Al. 1 /Service Connections excavations @ $20.00 = $20.00
A2. I /Additional Excavations same service ~ $10.00 = $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:
__l.f. ~ $0.30 =
0-1001.f. = $30.00 (78' trench)
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 = $85.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavahon permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk o~/a~.~'~O ~
I ' D~te ·
Permit Issued t~'~ 7/O~/e Permit No. ,.~
NDENT OF HIGH/WAYS
Peter W. Harris
!
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to thc Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
AU6r-16~2004 12:82
KEYSPAN GAS CONSTR
KEY~PAN ~)
REQUE~TFOR81'REE~OPEN~NG PERlglfT.
631 ?58 5136 P.04
PERMIT
, NO.
REA~N FOI~
ORIINlt¢~
~ BTA?E' [] ' NA~iIMU ~UFFoLK
COUNTY
/~,t..',d~ Il,t- o&- Z
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TOTAL P. 04
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
IB - Improper barricades
IL - Improper lights
ST - Sunken ~ench 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- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3