HomeMy WebLinkAbout405 Maple LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/28/08
* * * RECEIPT * * *
Receipt~: 26428
Transaction(s):
1 1
Permits
Reference Subtotal
573 $170.00
Check#: 15494
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 573
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
£ECEIV~
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Soul'old ]'owtl Cler~
Re£#TI00901268
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 11801
Name of Applicant
2) 405Maple La. Mattituck
Address
Owner of Premises Address
3)
4)
$)
1-4'x4' bellhole on the S/s of Maple Lane 345' e/o Grand Aveenue 345' e/o Grand Ave., to
install a gas service.
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other Trade's License No.
%14-08
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) 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
7) Starting Date:
8) Work Schedule:
, Block , Lot
Completion Date:
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 #
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 =
$150.00
$2o.oo
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
I.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
I.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 = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPER~T OF HIGHWAYS
TO WN//ffO/r~'r~?~7 YORK
Received by the Town Clerk
Permit Issued
Date
7' ,,.2 ~t/'~rmit NO. -.-~-- 7.5
Not__e: Permit expires one ( l) year from Dateoflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Depa~ment
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
l*t
2nd
4~h
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barricades
IL Improper lights
ST - Sunken trench or excavation
UTM Unable to measure (due to backfilling)
BUC - Building under Construction
WIP Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspectorholding forfinalsettlcmentofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE:
L OCATI(I~:
! OV~q:
'~V CF~K ORDER:
SURF&CE: i
Macadam Ror~ d
7/18/2008
405 MAPLE LN
MATTITUCK
T100901268
I~R.,'~ APPLICATION ~KETCH
Village Of
~0S$ STREET 1:
C~OSS S~F..EE T 2:
GRAND AVE
4O5
345'
MAPLE LN