HomeMy WebLinkAbout1530 New Suffolk AveTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 0~/26/10
* * * RECEIPT * * *
Receipt#: 91113
Transaction(s):
1 1
Permits
Reference Subtotal
663 $170.00
Check#: 19454
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 663
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
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 CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 1530 New Suffolk Avenue New Suffolk
Address
Owner of Premises
3) 1-4'x4' bellhole on the S/s of New Suffolk Ave., 265' e/o Grathwohl Rd., to install a gas
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.
Plumber's License No.
Other Trade's LicenseNo. .~ I /
Sigaatare of App~licant / /
8-17-10
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~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 .,Block ,Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Coveraae (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 anolications and permits: Basic Application Fee
Al. _l~/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.L = $10.00 -
i,f. @ S0.10:
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional 1£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
i.£. @ $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.
SItIt~TENDENT OF I~IGHWAYS
T? 'otSso "oL
Peter W. HarJ'is
-- t Date
Received by the Town Clerk 0O -/~ "/C~)
Date
Permit Issued ~ ~ O-trO Permit No. ~' ~ .~
Note: Permit expires one (l) year fromDateofIssuance. Noworktostaxtwithout48hournoticetotheSupcrintendentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
2.d
3~d
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 -lmpmper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
)iercel Plot ~ter: 101 minor: 46444000 Scale
(C) National Grid 8/17/10 10:28 AM