HomeMy WebLinkAbout250 Youngs RdTown Of Southold
P.O Box 1179
$outhold, NY 11971
Date: 04/08/09
Transaction(s):
1 I
Permits
* * * RECEIPT * * *
Receipt#: 44898
Reference Subtotal
619 $170.00
Check#:16947
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 619
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
R~CEIV~D
2009
Sou~o~dT~,n C~grk
Re£#T101006346
APPLICATION 1S HEREBY made to the Superintendent of Highways of the Town of Southold for lhe 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 Ihe 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
I) NATIONAL GRID- GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 250 Youngs Road Orient
o Owner of Premises Address
3) 1-4'x4' bellhole on the W/s of Youngs Ave. 300' n/o Main Rd. to install a gas servi~'.~--
4)
S)
6)
7) tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's__~License No. __
4-01-09
Date
s)
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 ail other necessary permits and licenses for this project.
c) Work covered by this apptication 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:
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) Securii¥:
a)
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
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and permits: Basic Application Fee $150.00
Al. I /Service Connections excavations ~ $20.00 = $20.00
A2. /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:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-1o0 l.f. = $50.00
l.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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ~/- ? - O t°
Date
Permit Issued ~-0¢~0 V PermitNo. ~:v /9
3oNDENT OF HIGHWAYS
UTHOLD, NEFYORK
Peter W. Harris
?
' Date
Not~e: Permit expires one (1) year from Date oflssuance, No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Pagc2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB- Improper barricades
IL Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC -Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE .~
LOCATIC~:
T owlq~
W~ ORDER:
SURFACE:
Macadam Ro~ ~ ~
4/1/2009
250 YOUNGS RD
ORIENT
T101006346
PERMIT APPLICATION SI/~TCH
Village Of
(~0S$ ST I~..EET 2~
MAIN RD
250
300'
4' f4~Bell Hole
YOUNG AVE