HomeMy WebLinkAbout3950 Pequash AveTown Of Southold
P.O Box 1 t79
Southold, NY 11971
Date: 02/17/09
* * * RECEIPT * * *
ReceiptS: 41683
Transaction(s):
1
Permits
Reference Subtotal
604 $170.00
Check#:16583
Total Paid: $170,00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 604
Permit No.
File No.
/
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York !1958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECEIVED
1 2 2009
Ref.#T100976176..
~,,,,,,,uld Town C,'erk
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 11501
Name of Applicant Address
2) 3950 Fleets Nk- Rd. (Pequash Ave.) Cutchogue
Owner of Premises Address
3)
4)
5)
6)
1-4'x4' bellhole on the S/s of Fleets Nk. Rd, 219' w/o Stillwater Ave, to install 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.
1-23-09
Date
5) 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 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: $
I1) 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)
b)
Bodily injury and property damage: $300,000/$500,000 Bodily Iv~iury, and $50,000 property daraage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. 1 JService Connections excavations ~ $20.00 =
$150.00
$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 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-I00 I.f. = $50.00
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 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 c:a9 ~/o~ ~e::~~ Date
Permit Issued c:a9 ~ / 7 -1~ 7 Permit No.
SUP.BRIF~ENDENT OF HIGHWAYS
vow OySOU*,HO etNEW
\ Peter W. Harris
Note: 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
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 Constr~ction
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
national§rid
~RMIT APPLICATION' SKETCH
Village Of
DATE:
L OCATI aN':
T OWN:
WCI~ ORDER:
1123/2009
3950 PEQUASH AVE C~OSSSr~T 1~..
CUTCHOGUE c~oss sr~ :~:
T100976176
STILLWATER AVE
N CROSS RD
SURFACE:
Macadam Ro~O ~
3950
219' 4' x~4' Bell Hole
PEQUASHAVE
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