HomeMy WebLinkAbout795 Laurelwood DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 12101108
* * * RECEIPT * * *
Receipt: 30948
Transaction(s):
1 1
Permits
Reference Subtotal
597 $170.00
Check#: 16267
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 597
re it No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00955664
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Sonthold 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 J~E~ NY 11801
Name of Applicant
2) 795 Laurelwood Drive
Laurel
Address
Owner of Premises Address
3)
4)
$)
6)
1-4'x4' bellhole on the W/s of Laurelwood Dr. approx. 355' s/o Heather Place to install a
gas service at ~795 Laurelwood 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.
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 #
¢) 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 ant>lications and permits: Basic Application Fee $150.00
Al. _l~/Service Connections excavations ~ $20.00 = $20.00
AZ?.. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
If. @ SO.lO --
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.E = $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 Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk / ~? - / ~ (~ (~
Permit Issued ,/~ //~ ~)Op/Date
· Permit No.
SUPERINTENDENT OF HIGHWAYS
To r6%oumom NE.W,YO
Peter W. Harris
Date
,5- ??
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
lnsflec~tor
· Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3rd
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 Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspectorholdingforfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
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Village Of
11/12/2008
795 LAURELWOOD Dlii~oss ~ET ~.,
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T100955664
HEATHER PL
PECONIC BAY BLVD
Ho.,.~ NO.
795
355'
LAUREL WOOD DR