HomeMy WebLinkAbout1000 Wickham AveTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/16/04
Transaction(s):
Permits
Receipt:
3521
Subtotal
$45.00
Check#: 3521
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 99586
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHXVAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100407442
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. - HICKSV1LLE. NY 11801
Name of Applicant Address
2) 1000 Wickham Avenue, Mattituck
Name of Owner of Premises Address
3) Wickham Avenue- bellhole w/s grass area behind the curb~ approx. 166' s/o Pike Street, for a cas service
installation to #1000
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
Electrician's License No. Other Tr~'s License No.
/~- (/ Signatu~'e of~pp~dafft
~,~ 07-26-04
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) Attach all other necessar~ 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:
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:
Completion Date
D-39
Pagelof3
12) Insurance Coveraee: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to thc Town:
13) Security:
a)
b)
TI 00407442
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoolications and permits: Basic Application Fee .....
Al. 1 /ServiceCannectionsexcavations~$20.00=$ 20.00
No.
A2. __/Additional Excavations same service ~ $10.00 = $
No.
$25.00
B. Excavations 18" in depth or less:
0-100 Lf. = $10.00
I.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f.: $30.00:
__ l.f. @ $o.3o:
Additional
D. Excavations 5' in depth and over:
0-100 1.f. = $50.00
I.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 Cl~rk of the Town vf Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
~U~HojeNT OF HIGH~yAYS
D, NE~eYORK
~ , D89~
Date
Permit No. ,ff~ 7
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Peamit must be available for inspection.
D-39 Page 2 of 3
Received by the Town Clerk ~t/~V~
Permit Issued ~"~ &/t~ Date
JUL-26-2004 10:00
PERMIT
, NO.
LOOA?ION
REASON FOR
.OPENING
W. OJPA
NO.
REQ'UEETED
E¥
APPROVED.
KEYSPAN GAS CONSTR
631 ?50 5136 P.02
KEYSPAN
eREQUEST FOR STREET'OPENING PERM~
[] STATE r-"] NASSAU EUFFOLI(
COUNTY
DEPAR~ENT . DIVISION
OAS OONSTR. MAI~. & SERVICES
T~
TOTAL P. 02
Co~>v Distribution:
Highway Depariment
Inspector
Applicant
Town Clerk
INSPECTOR,S RECORD
Inspection Date
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
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- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
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