HomeMy WebLinkAbout925 Town Harbor LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/17/09
* * * RECEIPT * * *
Receipt~! 43436
Transaction(s):
1 1
Permits
Reference Subtotal
613 $170.00
Check~: 16782
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 613
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
RECEIV~'D
2009
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
$outhold Town
Ref.#T100991939
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 oftbe
job site.
Print or Type
1) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 925 Town Harbor Lane Southold
Owner of Premises Address
3)
4)
$)
6)
1-4'x4' bellhole in grass area on E/s of Town Harbor La., s/o L' Hommedieu La, to
relacea gas service
tidal wetlands? *Yes No X
*If yes, other Town permits may be required,
Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
3-$-09
Date
5) a) Attachp~~tp~ansh~wingl~cati~n~fpr~p~sedexcavati~nandrelati~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 , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
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) 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 aonlications 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 -
I.£ ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.£ =
Additional I£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.£ = $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 thc 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 --~ -/0 - ~ ~
Permit Issued ,~ -/7 - O ~' Date Permit No. ~
SUPERINTENDENT OF HIGHWAYS
SOUTHO NEW
Peter OV. Harris
/3
Nolo: 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
2nd
4th
Findings(usecode)
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 lmproper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR - Ready to Repair
D-39 Page3 of 3
PERMIT
NO.
LOCATION
/~/A'ri ONAL
REQUEST FOR STREET OPENING PERMIT
~--~STATE ~ NASSAU
COUNTY [~ SUFFOLK
COUNTY
P. 05/05
'7~w,v oF
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. &
DATE OF
OPENING
DIVISION
SERVICES
DATE
SKETCH
L ' Ha m¢ i¢u
TOTRL P,05