HomeMy WebLinkAbout1015 4th StTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/28/11
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt#: 99682
Reference Subtotal
691 $200.00
Check~: 20514
Total Paid: $200.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksvitle, NY 11801
Clerk ID: LINDAC Internal ID: 691
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#T101213601
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 OPERATIONS DEPT.- 175 E. OLD COUNTRY RD. - HICKSVILLE, NY
11801
Name of Applicant Address
2) 1015 4th St. New Suffolk Owner of Premises Address
3)
1-4'x6' bellhole in the W/s of the road, approximately 58' s/o King St. and a 100' trench south in
the W/s grass area to install a gas main and service.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __ X__
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other Trade's License No.
03-18-11
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
D-39
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:
a)
Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anvlications and permits: Basic Application Fee
A I. /Service Connections excavations ~ $20.00 -
100' trench fee
A2. /Additional Excavations same service ~ $10.00 -
No.
$150.00
+ 20.00 hellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 I.t~ = $10.00 -
I.fi @ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. -
Additional If ~ .30 = of trench 96'
D. Excavations 5' in depth and over:
0-100 I.f. - $50.00
l.f. ~ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations @ $10.00 = $
Repairs same service @ $5.00 = $
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $200.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
NATIONAL GRID in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN/I~UTH..,QLD, N ~a~g?YORK
Date
Received by the Town Clerk
Date
Permit Issued Permit No.
Note: 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
1st
2nd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB- 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- lnspectorholdingfor finalsettlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
MA~17-2011
~FU~DN FO~
OPKN'NG
A'PPAOVED-'
GAS SALES PATCHOGUE 6317585182
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