HomeMy WebLinkAbout1035 Calves Neck Rd.¸1
Town of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/28/10
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
ReceiptS: 19304
Reference Subtotal
659 $170.00
Check~: 19304
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID: 659
Permit No.
File No.
TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, NewYork 11958 ,JUL 2 8 2010
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND RE _1~..~0[d ']'own Clerk
W.O.# T101152312
APPLICATION 1S 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) 1035 Calves Neck Rd. Southold
Owner of Premises Address
3) I-4'x4' bellhole on the N/s of Calves Neck Rd., 400' w/o Harper 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.
Plumber's License No.
Other Trade's License No.
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 ora Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Block , Lot
Completion Date:
Completion Date
9) Under which authority is the application made:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
I0) Estimated Cost of Proposed Work: $
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:
13) Security:
a)
h)
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 applications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 =
$150.00
$20.OO
A2. /Additional Excavations same service ~ $10.00 =
No,
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
I.£ ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.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
Permit Issued (z~q
Permit No. (-~S~
oNDENT OF HIGHWAYS
UTHOL :yWYO
Not~e: 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
3rd
Findings (use code)
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
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholdingforfinalset~lementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3