HomeMy WebLinkAbout2890 Highland RdTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/12/10
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
ReceiptS: 79653
Reference Subtotal
651 $170.00
Check~: 18862
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 651
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peeonie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.# T101127272
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 oftbe
job site.
Print or Type
1) NATIONAL GRID- GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY tlS01
Name of Applicant Address
2) 2890 Highland Rd. Cutchogue
Owner of Premises Address
3) 1-4'x4' bellhole on the W/s of Highland Rd., 275' s/o Bridle Lane 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~
Signature of Applicant
5-05-10
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoinlng 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 _, 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 Coverage (Atiach 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 properly damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
ors
b) Maintenance Bonded provided: 2years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. 1 /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 -
if. @ $O. lO -
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. -
Additional Iff ~ .30 =
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 = $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.
SU,~I]~NDENT OF ~H1GHWAYS
Peter W. Harris
Received by the ~o~n Cler~
Permit Issued ,D~-/,2 -/4.) Date Permit No. ~'~ S~t/
N0t~: 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
Cow Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
2nd
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
WlP - Work in 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
nationalgrid
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:PER.MIT APPLICATION SI~TCH
Village Of
5/5/2010
2890 HIGHLAND RD
CUTCHOGUE
T101127272
C~.OSS ~l~ET 1:
C~OSS ~'T F~E T 2:
BRIDLE LN
CROWN LAND LN
2890
275'
Bell Hole
HIGHLAND RD
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