HomeMy WebLinkAbout1275 Laurelwood DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/25/08
* * * RECEIPT * * *
Receipt~: 29299
Transaction(s):
1 1
Permits
Reference Subtotal
585 $170.00
Cash#: 15928
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 585
Permit No. ~/~), ,~/'
File No. '~
£~CEIV~D
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND R~q~Ii] '['(~wll CI~']t
Ref.#T100930914
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. -175E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant
2) 1275 Laurelwood Drive
Laurel
Address
Owner of Premises Address
3)
4)
1-4'x4' bellhole on the W/s of Laurelwood Dr., approx. 56' n/o Heather PI, to install a gas
service at the above location.
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
2)
Plumber's License No.
Other Tra~__
9-18-08
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving n detailed description of layout of excavation,
b) Attach all 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 , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy #
23/09 '08 TUE 13:43 FAX 631 765 6145 S0[~HOLD TOWN CLERK ~ Highway Dept, , ~002
SEP.~22-~UU8 02: 32 KEYSPA}{ ~§0 i~ I- .
c) S~te wh ~m~' polic-y of ~ertil]mtion on tilc with ~ Highway
d) Covcr~c Z~:lU~'~l ~gu d~d to thc Town:
Bodily in}my and prop~ty damage: S300.000/$500,000 I~hly
13) ,~..~:
a) Sm~y Bond or Centred Chcck
ors
b) Main~mc~ B~da:l pr~vld~d: 2 y~'~
14) Fees for n~ulii~t/~ns and ve~_ ;~: ][~si¢ A!mpli~.t/,'.on Fe~ ,
Al..l..=,/~-vic~ Coun~/ons =xcavafions ~ $20,00 =
/Atkl;tiona! ~x~vulJous ~ scrvir, c ~i~ S 10.00
provided i~ ',Ac ~ muounr
3y~
EXr.~'~ioa~ 18" in del~t o~
~lO0 Lt. m $10,00 -
Addit/~d
C=
Ex,~,,~tia~.~ lg" in dep~ t~ 5' i~ depth:
Additional lf. (~ ,30 =
~x~vm:lo~s 5' in dep~ aad
0-100 l.f. = $50.OO
Lf. ~ $0.50
NO.
U~lity Rcpair F. xcov~tion~ ~ $10.00 = $
~ai~ ~tmc scr~ic~ ~ S$.00 = $
Notice to public utili~ ~oof ~ b~ pm~d~d ~ aRa~h~l ~o ~h~ appllca~oa p~ior to i~u~cc of
TOTAL COST =
~ is ~by ~aated t~ ~ T~,~ Clog of I~ Tm~m ~ ~ald k~ i~uc a Highway Exc~wQ~'t l~'mk m;
KEYSPAN ]EfI~RG¥ DE LIV~I~¥ i~ a~r~mc~ ~ fids application.
Re.~.ived by ffm Tayto Cl~k ~'-
D~
P~mit No,
Corsv
.qi~vay Dcpa~tr~t
TOTAL P.002
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2~
3rd
4th
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- lnspectorholding forfinalseitlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE:
LOCATIaq:
T
WCRK ORDER:
._~
Macadam Rog d a_
PERMIT APPLICATION SKI/TCH
Village Of
9/19/2008
1275 LAURELWOOD [Z~ss sreeET h
LAUREL cxoss sr geET :,
T100930914
HEATHER PL
WOODSIDE LN
How NO.
1275
56'
Bell Hole
LAUREL WOOD DR
z