HomeMy WebLinkAbout895 Town Harbor LnTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/08/10
* * * RECEIPT * * *
ReceiptS: 86875
Transaction(s):
1 1
Permits
Reference Subtotal
654 $170.00
Check#: 19172
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 654
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEIVED
dUL 8 2010
APPLICATION/PERMIT FOR HIGI-VvVAY EXCAVATION AND REPAIR
W.O.# T101145513
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.
P~'int or Tyne
1) NATIONAL GRID - GAS CONSTR~ DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 895 Town Harbor Ln Southold
Owner of Premises Address
3) 1-4'x4' bellhole on the E/s of Town Harbor Ln., approx. 265' s/o Lhommedieu La., to
install a gas service.
4)
s)
6)
7)
tidal wetlands? *Yes
No X
*ffyes, other Town permits may be required.
Builder's License No.
Electrician's License No.
Plumber's License No.
Other Trade's License No.
PP
6-28-10
Dnt~
5) a) At~aeh 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 Excavation Permit
by the Town Clerk.
6) Tnx Map: Section ,Block ,Lot
7) Starting Date: Completion Date:
8) WorkSchedule:
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 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 pmporty damage.
13) Seeurltv:
a)
Surety Bond or Certified Cheek provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and eermits: Basic Application Fee
Al. _l~/Service Conneetinns excavations ~ $20.00 =
$150.00
$20.00
Ag. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10=
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f. =
Additional 1£ @ .30 =
D. Excavations 5' in depth and over:
0-1001.f. = $50.00
El. @ $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 oftbe Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk 7- ~' ~ / O
Permit Issued '7.- t9 --/O Permit No.
~T~DNDENT OF HIGHWAYS
P~er W. Harris
Note: Permit cxpi~s 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 Distribufion:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Da~
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
IB- Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
IJTM - Unable t~ measure (due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D--39 Page 3 of 3
nationalgrid
I~ERM1T APPLI~TION SKETCH
Village Of
DATE:
LOCATIa~:
T OWN:
Wi~RI( ORDER:
6/28/2010
895 TOWN HARBOR L~.oss ~r~Er l,
SOUTHOLD ~oss s~ 2,
T101145513
LHOMMEDIEU LN
HOEY RD
~dRFACE:
Macadam Roi
~m NO.
895
265'
311 Hole
TOWN HARBOR LN
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