HomeMy WebLinkAbout580 Oyster Ponds LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 09/11/08
* * * RECEIPT * * *
Receipt#: 28728
Transaction(s):
1
Permits
Reference Subtotal
584 $170.00
Check#: 15834
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 584
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
R£CEIV~D
Ref.#TlO~tl~d T~wrl Cler~,
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 thc 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 ail
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 Appticant
580 Oyster Ponds La..
Orient
Address
Owner of Premises Address
3)
4)
1-4'x4' bellhole in W/s of Oyster Ponds La., approx. 480' n/o Skippers La. to install a ~.ng
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.
Plumber's License No.
Other Trade's License No.
5)
6) Tax Map: Section
7) Starting 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:
Signature of Applicant
9-08-08
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) ARach all other necessary permits and licenses for this projecL
c) w~rkc~veredbythisapp~icatio~mayn~tc~mme~cebeforeissuanceofaHighwayExcavationPermit
by the Town Clerk.
~ Block , Lot
Completion Date:
Completion Date
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:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 proper~ damage.
13) Securig/:
a)
Surety Bond or Certified Check __ provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.fi = $10.00 -
l.~ @ $0.10 =
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 l.f. = $50.00
Lf. ~ $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.
SUPAF.~INTENDENT OF HIGHWAYS
Peter W. Harris
Notc: Permit expires one (I) year from Date of Issuance. No work to start without 48 hour notice to thc Supcrintcndcnt of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
lSt
2nd
3~
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- Inspector holding for final seltlement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
natioI- algrid
PERMIT APPLICATION SKETCH
Village Of
DATE:
LOCATI(~:
T O~,Vlq:
WCRK ORDER:
9t812008
580 OYSTER PONDS H~bss S~REET ~:
ORIENT ~oss s-r R~ET :,
T100924612
SKIPPERS LN
MAIN RD
SURFACE:
Macadam Ro~d--Z
580
480'
4' x~4' Bell Hole
OYSTER PONDS LN