HomeMy WebLinkAboutNorthern Cross RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/25/09
* * * RECEIPT * * *
Receipt~: 58227
Transaction(s):
1 1
Permits
Reference Subtotal
635 $213.20
Check#:17632
Total Paid: $213.20
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 635
Permit No.
File No.
TOWN OF SOUTHOLD R£CEIVED ~
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
AUG
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR .... ,
~oulllola Io¥~n ~erk
ReL#T1010~4028
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 d~scribed. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized insp~Clors to make necessary inspections of the
job site.
Print or Type
1) NATIONAL GRID - GAS OPERATIONS DEPT.- 175 E. OLD COUNTRY RD. - HICKSVII.I,I~ NY
11801
Name of Applicant Address
2) Northern Cross Road
Cutchogue
Owner of Premises Address
3)
4)
4) Builder's License No.
Electrician's License No.
1-4'x4' bellhole in the E/s paved area, approx. 80' s/o Pequash Ave., and a 145' trench in the E/s
grasss area, to install a gas main and service to house 730 Eastwood Drive.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No.
s)
Signature of Applicant
o) Attaeh 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) W~rkc~veredbythisapp~icati~nmayn~tc~mmencebef~reissuance~faHighwayExcavati~nPermit
by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting 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: $
I1) Remarks:
Completion Date:
Completion Date
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)
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 anolications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $20.00 =
100' trench fee
A2. /Additional Excavations same service ~ $ l 0.00 =
No.
$150.00
+ 20.00 bellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 I.£ = $I0.00 -
I.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. -
Additional 1f~.30 = of trench 145'
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 = $213.20
Authorization is hereby granted to the Town Clerk of the Tov. m of Southold to issue a Highway Excavation Pcrmit to:
NATIONAL GRID in accordance with this application.
Received by the Town Clerk
Permit Issued ~:~',~--'O ~/' DatePermit No. ~:~ '"~'-~
SUPERINTENDENT OF HIGHWAYS
TOW~q~_OUTHOLD, NfTW YORK
-P~ter W. H"afris "-'
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 Page 2 of 3
na~ona~3rm
REQUEST FOR STREET
] STATE [] NA~&AU SUFFOLK
PERMFr I IMI,SJOB~.~' IDATE / .
~ . ~ DATE OF
DEPAR~E~
APP~VED ~
SKETCH
N
TOTRL P.04
Copy Dis~bution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3fa
4th
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
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