HomeMy WebLinkAbout300 George RdTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/02/11
* * * RECEIPT * * *
Receipt#: 101774
Transaction(s):
1 1
Permits
Reference Subtotal
700 $170.00
Check~:20703
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 700
Permit No. f ,~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAI~0[b'0l~ Zov,,rl ~.~{~r~t
R/:CEIVED ~
W.O.# T101228281
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) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY I 1801
Name of Applicant Address
2) 300 George Rd
New Suffolk
Owners of Premises Address
3)
4)
5)
6)
7)
1-4'x4' hellhole on the N/s of George Rd. 350' e/o Fred Rd., to install a gas service.
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other Trade's Li o~~.~
~ignature of Applicant
4-27-11
Date
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 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
7) Starting Date: Completion 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:
, Lot
Completion Date
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy Pt
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
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-I00 1.f. $10.00 -
1.£ @ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.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 = $170.00
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.
SUPERI~DENT OF H I~?yVAYS
'
Peter W. Harris
Received by the Town C,erk ~/'t/
f/d./ D te
Permit Issued // Permit No.
Not__e: 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 Page 2 of 3
Co~v Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
] st
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB- Improper barricades
IL - Improper lights
ST - Sunken french 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 finalsettlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE:
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W(~,K ORDER:
SURFACE:
Macadam Ro~ d 2
LLI
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PERMIT AFPLICATION SKETCH
Village Of
4/27/2011
300 GEORGE RD
NEW SUFFOLK
T101228281
CROgS S'r I~ET 1:
~OSg ~REET %
FRED RD
NEW SUFFOLK RD
300
350'
Bell Hole
GEORGERD
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