HomeMy WebLinkAbout5050 New Suffolk Aveo Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/16/04
Transaction(s):
1 Permits
Receipt#:
3552
Subtotal
$115.50
Check#: 3552
Total Paid: $115.50
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 99583
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.#T100409499
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. - HICKSVILLI~ NY 11801
Name of Applicant Address
2) New Suffolk Avenue, Mattituck
Name of Owner of Premises
Addr~s
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:
3) New Suffolk Avenue -bellhole and a 235' trench in the n/s grass area~ win Meadow Lane.
Mattituck~ to install a gas main and service to house #5050
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? eYes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trad~ License No.
5) a) At~ach 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 necessa~ permits and licenses for this project.
c) Work coverod by this application may not commence beforo issuance of a Highway Excavation Permit
by the Town Clerk.
, Block , Lot
Completion Date:
Completion Date
Pagelof3
12) Insurance Coverage: (At~ach 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:
13) Secuhty:
a)
b)
TI00409499
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. _l__/Service Connections excavations ~ $20.00 = $20.00
$25.00
A2. /Additional Excavations same service ~ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 I.L = $10.00 -
l.~ @ $O. lO =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00
1351.f. ~ $0.30 -- $40.50
Additional
D. Excavations 5' in depth and over:
0-100 I.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 = :$115.50
Authorization is hereby granted to the Town Clerk of thc Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit Issued ~/~//~ ~
Date
Permit No. 3 ~,~c5~-'
SUP~'~/NDENT OF HIGHWAYS
Not__e: Permit expires one ( 1 ) year from Date of Issuance. No work to star~ without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1~t
2nd
3rd
Findings (use code)
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
D-39 Page 3 of 3
JUL-2?-2004 11:40 KEYSPAN GAS CONSTR 631 ?58 5138
lUEST FOR STREET OPENING PERMIT
~ SUFFOLK
PERMIT
REASON FOR ~ ~ ,
~/~ ~ ~/~ DATE OF
~ FOREMAN ~ ~ ~ ~
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REQU~T~u
/ GA8 CONSTR. MAI~. & SERVICES
APPROVED ~ ~DATE
SKETCH