HomeMy WebLinkAbout1525 West Creek AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/25/08
* * * RECEIPT * * *
Receipt#: 29300
Transaction(s):
1 1
Permits
Reference Subtotal
586 $170.00
Check#: 15911
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 586
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAI~rf!;O~:~ ]'~¥,,~ C~'erk
Re~#T100926915
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. - HICKSVILLE~ NY 1180!
Name of Applicant
2) 1525W. CreekAve.
Cutchogue
Address
Owner of Premises Address
3)
4)
1-4'x4' bellhole on the E/s of W. Creek Ave, approx. 427' n/o Midwood Rd., to install
gas service at the above location.
tidal wetlands? *Yes No X
*lf yes, other Town permits may be required.
Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
9-16-08
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~rk c~vered by this app~icati~n may n~t c~mmence bef~re issuance ~f a Highway Ex~avati~n 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)
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
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications 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"indepthorless:
0-100 1.£ = $10.00-
I.£~$0.10=
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 = $
Additional
Utility Repair Excavations ~ $10.00 = $
No.
r Repairs same service ~ $5.00 = $
Additional
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 ~ - ~ ~-- e:9 oc~
Date
Permit lssued ~3~ o23~-~ ~9,~' Permit No.
SU.~EI~NTENDENT OF HIGHWAYS
T?W SOUT.OLX), W
' -- Peter W. l)~rris '~
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 RECORD
Inspection Date
2,~
3r~
4th
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- lnspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
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nationalgrid
DATE:
L OC~ATICff:
T OWN:
WCI~ ORDER:
Macadam RoE
I~RMIT APPLICATION SKETCH
Millage Of
9116/2008
1525 W CREEK AVE ~OSS~R~T 1:
CUTCHOGUE c~oss SrR~T :,
T100926915
MIDWOOD RD
I.~,.,~e NO.
1525
4' x~4' Bell Hole 427'
W CREEK AVE
:1