HomeMy WebLinkAbout1545 Old Shipyard LnTown Of Southoid
P.O Box 1179
Southold, NY 11971
Date: 02/25/09
* * * RECEIPT * * *
Receipt~: 42285
Transaction(s):
1 1
Permits
Reference Subtotal
610 $170.00
Check~: 16721
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID: 610
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
Re£#TI00991947
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 of the
job site.
Print or Type
1) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant
2) 1545 Old Shipyard La.
Southold
Address
Owner of Premises Address
3)
4)
5)
6)
I-4'x4' bellhole in grass area on S/s of Old Shipyard La., 210' e/o Hobart Rd, to relace 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.
2-23-09
Date
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 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
7) Starting Date:
8) Work Schedule:
, Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
ll) Remarks:
Completion Date
12) Insurance CovcraRe (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)
b)
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. I /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$2o.oo
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
I.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional I£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 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 Soathold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk t'~ 'e~5~(~q
Date
Permit Issued e,q-~:} -Oq
Permit No. GlO
SUPERINTENDENT OF HIGHWAYS
TOWNJ~ITHOLD, NE.W/YORK
-- Peter W. H~ris
Da/e '
Notg: 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
Page2of3
Copy Distribution:
Highway Department
PERMIT
NO.
LODATION
REASON FOR
OPENING
W. OJPA
NO.
REQUESTED
-BY
APPROVED
SKETCH
REQUEST FOR STREET OPENING PERMIT
~--~STATE
P. 02
NASSAU
COUNTY ~ SUFFOLK
cou.Tv [~
M S JOB j DATE
.o. -~ ~ ~/~ ~/~/~
IFOREMAN
DEPARTMENT
GAS CONSTR. MAINT.& SERVICES
DATE OF
OPENING
DIVISION E,* '~,
DATE.
N
~L~
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
4th
Findings(usecod¢)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
1L - Improper lights
ST - Sunken trench or excavation
UTM Unable to measure (due to backfilling)
BUC- BuildingunderConstruction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3