HomeMy WebLinkAbout1500 Indian Neck LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/20/08
* * * RECEIPT * * *
ReceiptS: 22470
Transaction(s):
1 1
Permits
Reference Subtotal
571 $170.00
Check
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 571
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
$O!,~f~ ....
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) 1500 Indian Neck La. Peconic
Owner of Premises Address
3) 1-4'x4' bellhole on the E/s of Indian Neck La., 323' s/o Spring Rd.~ to inntnll 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 License No.
Signature of Applicant
6-09-08
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) Attach all other necessary permits and licenses for this project.
c) ~~rkc~veredbythisapp~icati~nmayn~tc~mmencebef~reissuance~faHighwayExcavati~nPermit
by the Town Clerk.
6) Tax Map: Section ~ Block
7) Starting Date: Completion Date:
., Lot
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the tiighway Department:
d)
13) Security:
a)
b)
Coverage required extended to the Town:
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 a~nlications and oermits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$2O.OO
B. Excavations 18" in depth or less:
0-100 l.f. = $10.OO -
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
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 Clerk ~ - / ? -0 oa
Date
Permit Issued ~' ' ~ -0 o~ Permit No.
SUPERINTENDENT OF HIGHWAYS
T~r~F SOUTHOLD. NEW YO~.~
Peter W. Harris
t Dhte
~- 7F
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.
D-39
Page 2 of 3
Copy Distribution:
High~vay Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2.~
Findings (usc 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- lnspectorholding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
nationalgrid
PER_MIT APPLICATION $,KETCH
Village Of
DATE:
LOCATI~q:
T OWN:
WCRK ORDER:
6/9/2008
1500 INDIAN NECK LN~oss ~E~r ~..
PECONIC c~o~ ~r~T 2:
T100887431
SPRING RD
DNE
SURFACE:
Macadam Rod
I-l~ NO.
1500
323' 4' x"~4' Bell Hole
INDIAN NECK LN