HomeMy WebLinkAbout1560 Green Hill LnTown of Southold
P.O Box 1179
Southold, NY 11971
Data: 10D~10
* * * RECEIPT * * *
Receipt#: 93604
Transaction(s):
1 1
Permits
Reference Subtotal
675 $170.00
Check#: 19817
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID: 675
Permit No. (~'~
Fi o No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICAT1ON~PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.# T101181937
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, ordinance~ 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 Tyne
1) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1560 Greenhill Ln Greenport
Owner of Premises Address
3) 1-4'x4' hellhole on the S/s of Sound Dr., approx. 19' e/o Green Hill Ln., to install a gas
service.
4)
S)
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 Lic. m~l No. _ ..~
~Si~f~ture of Applican~-~''
10-19-10
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) Attach all other necessary permits and licenses for this project.
e) Wock covered by this application may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation .............................................................
Backfill & Comp~ctJon .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
, Block
Completion Date:
, Lot
Comoletlon Date
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 thc Highway Deparlment:
d) Coverage required extended ~ thc Town:
Bodily injmy and property damage: $300,000/$500,000 Bodily Inju~, and $50,000 property damage.
13) Secaritv:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Foes for applications and oen'nits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$20.0O
A2, /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. -- $10.00 -
l.f. @ $0.10=
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
Lf. ~ $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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accord~ce with this application.
SUP~TENDENT OF HIGHWAYS
Peter ~.-Harris
- tO
Date
Received by the Town Clerk ~ 0 - ~ - hO I. 0
Date
Permit Issued [ 0 -~.$ --2.0 t t~ Permit No.
Note: Permit expires one (1) year from Date of Issuance. bio work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
I)-39 Page 2 of 3
Cony Distribution:
Highway Depaxtment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3:tl
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken t~-nch 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 settlcment ofexcavation
RFR - Ready to Repair
D=39 Page 3 of 3
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Village Of
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1560 GREEN HILL LN
GREENPORT a~oss
T101181937
GREEN HILL LN
INLET POND RD
~.m~ NO.
1560
19'
SOUND DR
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