HomeMy WebLinkAbout495 Tuckers Ln Town Of Southold
8 P.O Box 1179
outhold, NY 11971
* * * RECEIPT * * *
Date: 08/16/04
Transaction(s):
Permits
Receipt~:
3615
Subtotal
$45.00
Check#: 3615
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Intemal ID: 99582
Permit No.
File No.
TOWN OF SOUTHOLD
HIGI~VAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100412781
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 agree~ 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. - HICKSVILLE, NY 11801
Name of Applicant Address
2) 495 Tuckers Lane. Southold
Name of Owner of Premises
Address
3)
Tuckers Lane- bellhole n/s Tuckers Lane. 145' w/o Griswald Street. Southold. for a sas service installation
to 0495
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
4) Builder's License No.
Electrician's License No.
No X
*If yes, other Town permits may be required.
Plumber's License No.
Other T~)s License No.
/' / {.,/ Signature of'Al~ic~t
(.//
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 aH 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 , 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:
I)-39
Page I of 3
T100412781
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:
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoolications and ~rnnts: 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.L = $10.00
l.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. -- $30.00 =
~ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
l.fi @ $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 Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
S UPE~RqlnL*N~ENT OF H1GHWA~S
TOVfN OF S~H 0~I~ NE'~/V~~*,K
~p~ker '~. Harris
Received by ~e To~ Clerk /'t- ~
/ -- Date
Pemt Issued ~ Pemt No. ~ ~ ~
Note: P~it expi~s one {1 ) year ~om Date of ~suance. No work to smH ~thout 48 hour notice to ~e Su~dntmd~t of Highways.
P~it must ~ available for in~fion.
D-39 Page 2 of 3
CODy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1s~
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 bacIOill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
,~95 TUCKY_RS LN
$OUTHOLD
T10041P381
VILLAGE
CRO~ srP, EET: GRISWOLD S T
~URFACE:
M~m P~d
I-~e NO.
TUCKERS LN