HomeMy WebLinkAbout2020 E Gillette DrTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/02/10
* * * RECEIPT * * *
Receipt#: 91460
Transaction(s):
1 1
Permits
Reference Subtotal
668 $228.80
Check,:19540
Total Paid: $228.80
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 668
Permit No.
File No.
TOWN OF SOUTHOLD
H1GHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref#T101165145 8~; '" '/:I Ta':;~ ~!~r~
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. - HICKSVILLI~ NY
11801
Name of Applicant
2) 2020 E. Gillette Drive
E. Marion
Address
Owner of Premises Address
4)
1-4'x4' bellhole and a 100' trench in the N/s grass area of Cleaves Pt. Rd. and a 56' trench in
the E/s grass area of E. Gillette Dr. with a trench across the intersection~ 45' to install a gas mnin
and service.
Work Description and Location (Street Number, Hamlet, Cross Stree0
(a) ls construction located within 75 feet of tidal wetlands? *Yes
*lf yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
$)
No X
Plumber's License No.
08-30-10
Date
a) Attach plot plan showing location of proposed excavatlon and relationshlp 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
7) Starting Date:
8) Work Schedule:
, Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
ll) Remarks:
Comnletion 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:
13) Security:
a)
b)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 propetty damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for aDnlications and permits: Basic Application Fee
Al. /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 I01'
$99.00)
B. Excavations 18" in depth or less:
0-100 i.f. = $10.00 -
l.f. ~ $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 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 = $228.80
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.
Received by the Town Clerk ~ - ~ -
Permit Issued 4 --02-- /d.) Date
Permit No.
SUP~TENDENT OF HIGHWAYS
TqWN O~ SOUTHOLD~EW YORK
~ --Peter W.~H~rris
Date
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
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 - Workin Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
AUG-2?-2810 11:18 GAS SALES PATCHOGUE 6317585182 P,02
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PERN~M, IT MIS JOB~'~' -- ,_ DATE_
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SK~CH
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