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HomeMy WebLinkAbout170 Oyster Ponds LnTown of Southold P.O Box 1179 Southold, NY 11971 Date: 08/26/10 * * * RECEIPT * * * Receipt~: 91111 Transaction(s): 1 1 Permits Reference Subtotal 662 $170.00 Check~: 19426 Total Paid: $170.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 662 Permit No. File No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958 (631) 765-3140 RECEIVED 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) 170 Oyster Ponds Lane Orient Owner of Premises Address 3) 1-4'x4' bellhole on the W/s of Oyster Ponds La., 157' s/o Main Rd., 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 License No. 8-11-10 Date a) Atta~hp~~tp~ansh~wing~~~ati~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 , 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 Coveraee (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 property damage. Surety Bond or Certified Check provided in the total amount of $ Maintenance Bonded provided: 2 years or 3 years 14) Fees for aonlications and oermits: 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 l.f. = $10.00 - l.f. @ SO. lO = 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 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 accordance with this application. Received by the Town Clerk ~'- / c~. / o~ Date Permit Issued oO - ,n9 (,' -/O Permit No. (~ ~ ~. SUPfi,~T~NDENT OF HJ~HWAYS TO~VN O~OUTHOLD, ~E'%V YORK Date Note: Permit expires one (I) 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 Page2of3 Copy Distribution: Highway Department Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date 1st 2nd 3rd 4th Findings(usecode) Applicant Notified (To Permit Clerk) REMARKS CODE lB- 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 - Improper backfill (too high) (not sufficient) HFS- lnspectorholding forfinalsettlementofexcavation RFR - Ready to Repair D-39 Page 3 of 3 )~erce~ Plot Center: ma'or: 114 minor: 27776400 Scale = 1:7,,2.02 ~Z~~' ~ t,:, ":'~ .........  ~ 1~",'?: _ . ,, ~, , / / s 7 ~ 9 (o, o) ~ 2 ~ [ ~ s ?,' ~(o, o) 1 ~ ] 4 s ~ ~7 ~ / ~. I . ~',.: , ~oo f m ' ~,~ ~ .. t ~ ~ ,_, ~/. ~--~ (C) National Grid 8/11/10 10:02 AM