HomeMy WebLinkAbout3105 Peconic LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/26/08
Transaction(s):
1
Permits
* * * RECEIPT * * *
Receipt#: 30897
Reference Subtotal
595 $170.00
Check#: 16266
Total Paid: $170.00
Name:
National, Grid - Gas Constr Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 595
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£#TI00955350
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,E_ NY 11801
Name of Applicant
2) 3105 Peconic Lane
Peconic
Address
Owner of Premises Address
3)
4)
5)
6)
1-4'x4' bellhole on the W/s of Peconic La. approx. 267' e/o North Rd. to install a gas
service at #3105 Peconic Lane
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.
Date
$)
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) At~ach all other necessary permits and licenses for this project.
c) Work covered by this applicatlon 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:
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)
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
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and permits: Basic Application Fee $150.00
Al. I /Service Connections excavations ~ $20.00 = $20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. @ S0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional Iff ~ .30 =
D. Excavations 5' in depth and over:
0400 l.f. = $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
Date
Permit Issued ~/t/ ~ ,~ ~ ~> ~ Permit No.
SUPEg~tT.~NDENT OF HIGHWAYS
Peter W. Harris
Date
Not__e: 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
Page2of3
Copy Distribution:
Highway Department
·
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORI)
Inspection Date
i~t
3rd
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- Inspector holding for final settlement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
nationalgrid
DA1.E:
LOCATIOn:
OWN:
tar (F-.I~ ORDER:
SURE&CE.'
Macadam ROE
PliltMIT iPPLICA'I'IO~ SKETCH
Village Of
11/12/2008
3105 PECONIC LN
PECONIC
T100955350
CROSS
CROSS
NORTH RD
3105
x 4.~B~ 267'
4' II Hole
PECONIC LN
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