HomeMy WebLinkAbout250 Wendy DrTown Of Southold
P,O Box 1179
Southold, NY 11971
Date: 12/08/08
Transaction(s):
1
Permits
* * * RECEIPT * * *
Receipt#: 31160
Reference Subtotal
599 $170.00
Check#: 16371
Total Paid: $170.00
Name:
National, Grid - Gas Constr, Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 599
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£#T100961735
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. - HICKSVII J~E: NY 11801
Name of Applicant Address
2) 250Wendy Drive Laurel
Owner of Premises Address
~)
4)
$)
6)
1-4'x4' bellhole on the N/s of Wendy Drive 200' w/o Peconic Bay Blvd, to install a o. ag
service at #250 Wendy Drive
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.
Signature
12-02-08
Date
s)
a) Atta~hp~~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) 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/4
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 property 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 at~nlications and permits: Basic Application Fee
Al. I /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 l.f. = $10.00 -
I.£ @ $O. lO =
Additional
Excavations 18" in depth to 5' in depth:
0-100 hr. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 hr. = $50.00
hr. ~ $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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application,
Received by the Town Clerk /~- ~ ~ - O ~
Date
Permitlssuedt/o~ ~ -O~' PermitNo.
~ENT OF HIGHWAYS
Peter W~Harris
Not~e: Permit expires one (l) year fromDateofIssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (duc to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE:
LOCATIa~':
T OWN:
W C~t.K ORDER:
~RFACE:
Macadam Ro~
12/1/2008
250WENDY DR
LAUREL
T100961735
PERMIT APPLICATION SKETCH
Village Of
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(~OS$ S~ F~ET 2:
PECONIC BAY BLVD
250
4' x~4' Bell Hole
200'
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JWENDY DR
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