HomeMy WebLinkAboutCleaves Point RdTown of Southold
P.O Box 1179
Southofd, NY 11971
Date: 10/28/09
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt/h 60996
Reference Subtotal
639 $208.70
Check#:17956
Total Paid: $208.70
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 639
Permit No.
File No.
TOWN OF SOUTHOLD ECg I V~ D
R
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, NewYork 11958 ~,l 2 8 2009
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REI~I-~-OlJ__... ,,, ,,'r-,
Ref.#T101075340
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 OPERATIONS DEPT.- 175 E. OLD COUNTRY RD.- HICKSV1LLE~ NY
11801
Name of Applicant
2) Cleaves Point Road
East Marion
.Address
Owner of Premises Address
3) 2-4'x4' bellholes and a 130' trench in the N/s grass area, e/o Gillette Dr, to ingtall a gas main and
service to house 0290 Cleaves Pt. Road
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
X
5)
Electrician's License No. Other Trade's License No.~
Signatnre of AppliCant
10-22-09
Date
a) Attach 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) Tax Map: Section ., Block
7) Starting Date: Completion Date:
8) Work Schedule:
Lot
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:
D-39
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)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check
of $
b) Maintenance Bonded provided: 2 years or
14) Fees for applications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $20.00 =
100' t~ench fee
A2. /Additional Excavations same service @ $10.00 =
No.
provided in the total amount
3 years
$150.00
+ 20.00 bellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
O-lOO I.£ = $lO.OO -
1.f. @ $0.10
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional If ~ .30 = of trench 130'
D. Excavations 5' in depth and over:
0-100 1.f. = $50.00
l.f. ~ $0.50 - $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $208.70
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
NATIONAL GRID in accordance with this application.
Received by the Town Clerk /d,) - ~ ~- O,,~
Date
Permit Issued /d.) ' ,~7 ~ - 0,~ Permit No.
SUP.~K'1~g~ENT OF HIGHWAYS
TOWN OF SOZJTHOLD, NEWrt'ORK
Peter W. Harris
/Date /
Note: Permit expires one ( l ) year from Date of Issuance. No work to star~ 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
2nd
3,d
4~h
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 - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
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REQUEST FOR STREE~r' ~ ~
] STATE [] NASSAU SUFFOLK
PERMIT MIS JOB~ -- I DATE / _ '
.o. I"°. ~// /=~3~ I /=/~/~
REASON FOR
TOTAL P.03