HomeMy WebLinkAbout3270 Peconic Bay Blvd RECEIVED
Permit No. (~"'"J ~ TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
FileNo. (~qL~ PeconicLane OCT 27 ~010
Peconie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND l~ YOWl] Cbrk
W.O.# T101178727
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the iMuance 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 ali
applicable laws, ordinances, codfl and regulations, and to permit authoriztd inspectors to mske necessary inspections of the
job site.
Print or Tyne
I) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 3270 Peconic Bay BIvd Laurel
Owner of Premises Address
3) 1-4'x4' bellhole on the Els of Peconic Bay Blvd., approx. 685' n/o Wendy Dr., to install a
gas service.
4)
S)
6)
7)
tidal wetiands? *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 Licf, n~ No.
~L [S~u/Ve o f~Applica n'C'x,..
Date
5) a) Atta~hp~~tp~ansh~wing~~cati~n~fpr~p~sedex~avati~nandre~ati~nshipt~adj~iningpremises~r
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
7) Starting Date:
8) Work Schedule:
Phase
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
Block
Completion Date:
, Lot
Completion Date
!0) Estimated Cost of Proposed Work: $
I1) Remarks:
12) Insurance Coveraan (AUach 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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /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 -
l.f. @ S0.10=
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 hf. = $50.00
l.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.
Received by the Town Clerk [ 0- ~e] ~ [
Date
Permit Issued [ 0 - ~ ~ - [0
Permit No. (a '"] ~
SU~ENDENT OF HIGHWAYS
Peter W~ [larri~-
Date
N~tg: Permit expims one (1) year from Dateoflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
permit must be available for inspection.
D-39 Page 2 of 3
nationalgrid
DATE:
LOCATION:
T OWN:
WCI~K OP~DER~
WURFACE ~
Macadam Rog d~:
_J
I~RMIT ~ICATION SKETCH
Village Of
10/25/2010
3270 PECONIC BAY B,I:Ad~ ~Er ]..
LAUREL moss ~,T 2,
T101178727
WENDY DR
DELMAR DR W
3270
685'
4' Bell Hole
I PECONIC
BAYBLVD
Copy Distribution:
Highway Departmem
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
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 sufficiem)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
Town of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/27/10
* * * RECEIPT * * *
Receipt"8: 93582
Transaction(s):
1 1
Permits
Reference Subtotal
674 $170.00
Check,:19849
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID: 674