HomeMy WebLinkAbout825 Hortons LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 01/06/09
* * * RECEIPT * * *
Receipt#: 35576
Transaction(s):
1 1
Permits
Reference Subtotal
602 $170.00
Check#: 16474
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINE)AC Internal ID: 602
Permit No. !
File No. ~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pecooic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECEIVED
Re£#TL00968964..
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. - HICKSVII,I,~ NY 11801
Name of Applicant Address
2) 825 Hortons Lane Southold Owner of Premises Address
3)
4)
5)
6)
1-4'x4' bellhole on the E/s (gas main)~ hse. on W/s of Hortons La., approx. 225' n/o
Sunnyside Ave., to install a gas service at #825 Hortons La.
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.
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) W~rkc~veredbythisapplicati~nmayn~tc~mmencebef~reissuance~faHighwayExcavati~nPermit
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:
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 Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
nfS
Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlicafions and permits: Basic Application Fee
Al. _l~/Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.00
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.t~ =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.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 / ~ 'fi- O ~
Date
Permit Issued / -& ~O¢~' Permit No. ~, ~:9~..
SUPE~.P.P.P.P.P.P.P.P~ENDENT OF HIGHWAYS
TOX~'N O~SOUTHOLD; ~qEW YOP~_
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
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB -lmpmper barricades
1L - 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 final settlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
nationalgrid
PERMIT APPLICATION SKETCH
Village Of
DAT[:
LOCATI(~:
T OW~:
12/22/2008
825 HORTONS LN
SOUTHOLD
T100968964
(~OSS STF~T 1:
(~OSS ~TF2/I~T 2:
SUNNYSIDE RD
NORTH RD
SUF. FACE:
Macadam
825 j
225'
¸mm
4' x~4' Bell Hole
HORTONS LN