HomeMy WebLinkAbout770 Pinewood Dr Town Of Southold
P. 0 Box 1179
Southold, NY 11971
Date: 02/17/09
* * * RECEIPT * * *
ReceipUt: 41685
Transaction(s):
1 1
Permits
Reference Subtotal
606 $202.70
Check#: 16641
Total Paid: $202.70
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 606
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION
Re£#T100976174
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) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVI1J~l~ NY ! 1801
Name of Applicant Address
2) 770 Pinewood Drive
Cutchogue
Owner of Premises Address
3)
1-4'x4' bellhole in the paved area of Southern Cross Rd.~ a 4'x4' bellhole in the grass area at the
southwest corner of Pinewood Dr.~ and a 110' trench in the W/s grass area of Pinewood Dr.~ to
install a gas main and service.
4)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction I~ated within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
No X
Plumber's License No.
Other Trade's License No.
02/04/09
Date
5) a) At~achpl~tplansh~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
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:
D-39
12) lnsuranceCoverage: (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 properly damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
A 1. /Service Connections excavations @ $20.00 =
100' trench fee
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
+ 20.00bellhole +30.0of or
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional If ~ .30 = oftreuch 110'
D. Excavations 5' in depth and over:
O-lOO 1.£ = $50.0O
l.~ @ $0.50 -- $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided and atiached to this application prior to issuance of
permit.
TOTAL COST = $202.70
Authorization is hereby granted m the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUP~q~ENDENT OF ~tlGHWAYS
Peter W. Harris
?
/ Da{e
Received by the Town Clerk
Date
Permit Issued C~ ~ / 7~ C~' Permit No.
Note: 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 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - 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- lnspectorholding for final settlement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
09:10 KEY~PAN GAS CONSTR 631 758 5136
na[ ona rm
REQUEST FOR STREET OPENING PERMJT
LOgaN
I
A~VED
SK~H
TOTAL P.02