HomeMy WebLinkAbout715 Pequash AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/29/08
* * * RECEIPT * * *
Receipt~: 28373
Transaction(s):
1 1
Permits
Reference Subtotal
583 $170,00
Check#: 15762
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 583
Permit No.
File No.
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECEIVEO
Ref.#Tl0091$g~lhO|d ]'OWn C/Ofh
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 Address
2) 715 Pequash Ave. Southold
Owner of Premises Address
3)
4)
S)
1-4'x4' hellhole on the S/s of Pequash Ave., approx. 200' e/o 1't St, to reconnect a gas
service
tidal wetlands? *Yes
Builder's License No.
Electrician's License No.
No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Tra~
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
public streets or areas, and giving a detailed description of layout of excavation.
b) AHach 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
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: $
Il) Remarks:
, 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 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
ors
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for atmlications and hermits: Basic Application Fee
Al. 1 /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.f. - $10.00-
l.f. ~ $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
1.~ @ $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
Permit Issued oc.,9/~/,/cv ~.~ Date Permit No.
SUPERINTENDENT OF HIGHWAYS
TO'~/~x~' ~Q~ 0~ SOUTHO?Q~ ;ORK ~'~,
Peter W. Harris
~ Date · t -
Note: Permit expires one (I) 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 Page 2 of 3
Copy Distribution:
llighway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l~t
Findings(usecode)
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 -lmproper backfill (too high) (not sufficient)
HFS Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
national§ri
DATE:
L OCATI CI~:
TOWN:
WCRK ORDER:
SURFACE:
Macadam Ro~
PERMIT APPLICATION SKETCH
Village Of
8/25~2008
715 PEQUASH AVE
CUTCHQGUE
T100918471
~OSS ~REET 1:
1 ST ST
WILLOW ST
715
E~ 200'
4' x~4' Bell Hole
PEQUASH AVE