HomeMy WebLinkAbout933 New Suffolk RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/22/09
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
ReceiptS: 46323
Reference Subtotal
624 $170.00
Check,:17015
Total Paid: $170.00
Name:
National, Grid - Gas Constr, Dept
175 E Old Country Rd
Hicksvi!le, NY 11801
Clerk ID: LINDAC Internal ID: 624
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
2009
Ref.#T10]~Dt.~280-, ~.~,¥~, ~/'~
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 thc 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 lo 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. - HICKSVII,I,E~ NY 11801
Name of Applicant Address
2) 933 New Suffolk Rd. Cutchogue Owner of Premises Address
3)
4)
s)
6)
7)
1-4'x4' bellhole on the Els (gas main is on W/s)~ of New Suffolk Rd, 1~000' s/o Main Rd.
to install a gas service.
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.
4-20-09
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~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 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 (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 property damage.
13) Securii¥:
a) Surety Bond or Certified Check provided in the total amount
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /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 -
Lfi @ S0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.fi = $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.
SUPEI~htTt~NDENT OF HIGHWAYS
TO~(Iq OF~ OUTJ~IOLD/,I~EW YORK
Peter W. Harris
Date
Received by the Town Clerk 3/-~37~ - Off'
Date
Permit Issued t-/-~'~vc)'-D~ PermitNo. ~ c~ L/./
Note: 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
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- lnspector holding for final settlement ofexcavation
RFR- Ready to Repair
D~39 Page 3 of 3
nationalgrid
I~IBI~ APPLICATION SKETCH
Village Of
DATE ~
L OCATI (l'i':
T OWN~
Wt~[( ORDER:
4/20/2009
933 NEW SUFFOLK Rl~oss sr~,T ],
CUTCHOGUE caoss sr~T =,
T101013280
MAIN RD
CEDARS RD
Macadam
933
1000' x~47
4' Bell Hole
NEW SUFFOLK RD