HomeMy WebLinkAbout45655 County Rd 48Town Of Southold
P,O Box 1179
Southold, NY 11971
Date: 04/01/09
* * * RECEIPT * * *
Receipt'8: 44492
Transaction(s):
1 1
Permits
Reference Subtotal
617 $170,00
Check#:16918
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 617
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAYATION AND REPAIR
RECEIVED
Ref.#Tl010~hOId 1'own Clerk
APPLICATION IS HEREBY made to the Superintendent of Highways oftbe 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 to permit authorized inspectors to make necessary inspections of the
job site.
Print or Tyne
1) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLI~_ NY 11801
Name of Applicant Address
2) 45655 County Rd. (Cty Rd. 48) Southold
Owner of Premises Address
3) 1-4'x4' bellhole on the E/s of Younts Ave, 95' n/o County Rd. 48 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.
Plumber's License No.
Electrician's License No.
Other Trade's Licen .
Sigfiature of App~icanir
~-26-09
Dote
5)
a) Atta~hp~~tpiansh~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:
., Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Back/ill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
I0) 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) Security:
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoolications 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 -
~.~ @ $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:
0-100 I.f. = $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 g~anted 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 ~ '~f ~O
Date
Permit Issued ~7/-/- 6) ~
SUPERIN~T~NDENT OF HIGHWAYS
TOW)4~'OF ~5OUTHOLD, NF~ORK
Peter W. Harris
Permit No. &/?
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 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~
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- lnspector holding for finalset~lementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
DATE:
LOCATIC~I:
T
WCIt. K ORDER:
Macadam Rold~
PERMIT APPLICATION SKETCH
Village Of
3/26/2009
45655 COUNTY ROADui. Sss sr~'~'r ].,
SOUTHOLD ,cr,.oss ~E'r ',',
T101003813
COUNTY 48 RD
NORTH RD
45655
4' x~4' Bell Hole 95'
YOUNGS AVE
Z
O
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