HomeMy WebLinkAbout1655 Inlet Pond RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/26/08
* * * RECEIPT * * *
Receipt#: 29309
Transaction(s):
1 1
Permits
Reference Subtotal
588 $170.00
Check#: 15958
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 588
Permit No. ~ ~
File No. ~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECEIV:~
Soplhc, l~ Town
Ref.#T100930493
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. - HICKSVH,!~I~_ NY 11801
Name of Applicant
2) 1655 Inlet Pond Rd.
Greenport
Address
Owner of Premises Address
3)
4)
5)
4'x4' bellhole on the E/s of Inlet Pond Rd.~ approx. 216' n/o Rockcove La.~ to install a gas
service to house #1655.
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.
9-24-08
Date
5)
a) Attach plot plan showing location of proposed excavatlon and relationship to adjoinlng premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach ali 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: $
Il) 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)
h)
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
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.OO
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10
Additional
C. Excavmions 18" in depth to 5' in depth:
0-100 I.f. =
Additional I£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
kf. @ $0.50 = $
Additional
NO.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided and atiached to this application prior to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Date
Permit Issued Permit No.
SUP~,.R4-N~NDENT OF HIGHWAYS
TOWN OF~$OUTHOLD, NEW/fORK
Peter W. Harris
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 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~d
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
W1P - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- lnspectorholdingforfinalseRlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
SEP-2t-2008 05:14
KEYSPAH GAS CONSTR
r~;on~e;J ·
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO.
LOCA~ON
REASON FOR
OPENING
W. OJPA
NO.
I']STATE' "ASS'USUFFOLK
.MIS JOB DAT~/
' .o. ~o ~o~a
REQUESTED
BY
APPROVED
FOREMAN
' DEPARTMENT '
GAS CONSTR. MAINT.& SERVICES
DATE OF
OPENING
DIVISION
DATE
SKETCH
N