HomeMy WebLinkAbout50 Pequash AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/22/08
* * * RECEIPT * * *
Receipt#: 27966
Transaction(s):
1
Permits
Reference Subtotal
579 $170.00
Check#: 15685
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 579
Permit No.
.leNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Pecooic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REP~
Re£#TI00910512
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 thc 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 Address t-~
LM
2) 50 Pequash Ave. Cutchogue Owner of Premises Address ~'
3) 1-4'x4' belihole on the S/s of Pequash Ave.~ approx. 75' northwest of Midwood Rd. to ~
install a gas service.
4)
5) tidalwetlands? *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~~ __
Signatu~
8-13~8
Date
5) a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandrelati~nshipt~adj~iningpremises~r
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) 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
Phasg
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
I1) 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
ors
Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.0o
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
~.~ @ $O.lO =
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 1.£. = $50.00
l.f. ~ $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 CIc[k ~
OC~o~ )loc/Date
Permit Issued ~¢ 0)? o" Permit No.
Note: 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.
Page2of3
D-39
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2r~
3rd
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 finalsettlemant ofexcavation
RFR- Ready to Repair
D-39 Page3of3
REQUEST FOR STREET OPENING PERMIT
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W. OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
r~STATE ~-] NASSAU
COUNTY r-~ SUFFOLK
cou.
MIS JOB
FOREMAN ' DATE OF
' lOP.Nme
~GAS CONSTR. MAINT. & SERVICES I DATE
TOTRL P,