HomeMy WebLinkAbout945 Gillette DrTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/01/10
* * * RECEIPT * * *
Receipt~: 92699
Transaction(s):
1 1
Permits
Reference Subtotal
673 $170.00
Check#:19706
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 673
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEI~
OC~ ] 2011)
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR $ou~hold Town
W.O.# T101171552
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
I) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSV1LLEn NY 11501
Name of Applicant Address
2) 945 Gillette Drive E. Marion
Owner of Premises Address
3) 1-4'x4' bellhole on the E/s of Gillette Drive, 100' s/o Manor PI., to install a gas service.
4)
5)
6)
7)
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 ~,~lse N~q~
'
9-29-10
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 Excavatlon 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: $
Lot
Completion Date
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) 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 I.f. = $10.00-
~.~ @ $O.lO-
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
Additional Iff ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.£ ~ $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.
SUPEI~ENT OF HIGH~/AYS
Peter W. Harris
Received by the Town Clerk /t~ - /'- rd.) Date
Date
Permitlssued f~9~/-~/~) PermitNo. ~:) ~;~{~
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-g9 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
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- BuildingunderConstmction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
~ercei Plot Center: maior: :114 minor: 07459700 Scale = 1:48.02
~ (4, s) ) e/ ~ .~:,;~ (s,
1 2 3 4 5 6 7 8 9 (0, O) 3 4 5
(C) National Grid 9/28/10 2:30 PM