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HomeMy WebLinkAbout33105 Main RdTown of Southold P.O Box 1179 Southold, NY 11971 Date: 04/08/11 * * * RECEIPT * * * Receipt'8: 100168 Transaction(s): 1 1 Permits Reference Subtotal 694 $170.00 Check~:20568 Total Paid: $170.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LYNDAR Internal ID: 694 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 W.O.# T101219841 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 11801 Name of Applicant Address 2) 33105 Main Rd. Cutchogue Owners of Premises Addresss 3) 1-4'x4' hellhole on the E/s of Cox La., 83' n/o Main Rd., to install a gas service. 4) $) 6) 7) tidal wetlands? *Yes No X *If yes, other Town permits may be required. Builder's License No. Electrician's License No. Plumber's License No. Other Trade's License No. 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) ARach all other necessary permits and licenses for this project. c) Work covered by this application maynotcommencebeforeissuanceofaHighwayExcavationPermit by the Town Clerk. 6) Tax Map: Section ,Block ,Lot 7) Starting Date: Completion Date: 8) Work Schedule: Phase Excavation ......................................................................... Facility Installation ............................................................... Bacldlll & Compaction ......................................................... Pavement Replacement ......................................................... Completion Date 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: $ 11) Remarks: 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) Secudt¥: 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 permits: Basic Application Fee Al. 1 /Service Connections excavations ~ $20.00 = $150.00 $20.00 A2. /Additional Excavations same service ~ $10.00 = No. B. Excavations 18" in depth or less: 0-100 l.f. - $10.00 - I.f. ~ $010 = Additional Excavations 18" in depth to 5' in depth: 0-100 I.t~ = Additional I£ @ .30 = D. Excavations 5' in depth and over: 0-100 l.f. - $50.00 I.£ ~ $0.50 = $ Additional No. Additional Utility Repair Excavations ~ $ I 0.00 = $ 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 = $170.00 Authorization is hereby granted to the Tow~a Clerk of the Town of Southold to issue a Highway Excavation Permit to: KEYSPAN ENERGY DELIVERY in accordance with this application. Received by the Town Clerk 14 '/3 'o 0 Date Permit Issued I~ '~- 0'~9 II, Permit No. ~qt./ SUPERINTENDENTDF HIGHWAYS Peter ~. Harris Not~e: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways Permit must be available for inspection. D-39 Page 2 of 3 Copy Distribution: Highway Department inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date 15t 2nd 4th Findings (use code) Applicant Notified (To Permit Clerk) REMARKS CODE lB improper barricades IL Improper lights ST Sunken trench or excavation UTM - Unable to measure (due to backfilling) BUC - Building under Construction WIP - Work in Progress DB - Improper backfill (too high) (not sufficient) HFS Inspector holding for final settlement of excavation RFR Ready to Repair D-39 Page 3 of 3 nmionalgrid DATE .' L OCATI Ct~'.. T OWN: WCI~K ORDER: CO Macadam Ro~ d ~ o 7 © 415/2011 33105 MAIN RD CUTCHOGUE T101219841 PE~ APPLICATION SKETCH Village Of CROSS ~TREET 1." C~0S$ :~f i~E T 2.' MAIN RD COUNTY ROAD 48 33105 83' 4' Hole COX LN