HomeMy WebLinkAbout2735 Pequash AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/20/08
* * * RECEIPT * * *
Receipt: 22471
Transaction(s):
1 1
Permits
Reference Subtotal
570 $170.00
Check
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 570
File No.
TOWN OF SOUTHOLD
HIGHgVAY DEPARTMENT
Peeonic Lane
Peconic, New York 11958
(631) 765-3140
£ECEIV~D
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR ,JlJ~\l I 2J 2008
Ref.#T100889261
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold ~r0tl~ ~'~s~ ~n~[' ~$~'il C]OI'[~
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. - H1CKSVII.I.I~_ NY 1 lg01
Name of Applicant Address
2) 2735Pequash Ave. Cutchogue
Owner of Premises Address
3)
4)
1-4'x4' bellhole on the E/s of Pequash Ave. 285' southeast of Old Pasture Rd, to install a
gas service
5) tidalwetlands? *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.
Date
a) Attachpl~tplansh~wingl~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) workc~veredbythisapplicati~nmaynotcommencebeforeissuanceofaHighwayExcavati~nPermit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion 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: $
I1) Remarks:
Lot
Comoletion Date
12) Insurance Coverage (Atiach 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 lnjury, and $50,000 property damage.
13) Security:
a) Surety Bond or Certified Check provided in the total amount
nfS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and permits: Basic Application Fee
Al. i /Service Connections excavations ~ $20.00 --
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$2o.0o
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
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 ~'~ - ! ~fi ~ O oc~
Date
Permit Issued ~, - d.-e9 ~.9 33` Permit No.
SUPERINTENDENT OF HIGHWAYS
TOJ~N-OF SOUTHOLD, NEW YORK
Peter W. Harris
7 ~)at~
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:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
1L - 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 settlement ofexcavation
RFR Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE:
L OCATICi~:
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WORK ORDER:
SUI~FACE:
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I~P..MI'T APPLICATION SKETCH
Village Of
6/1212008
2735 PEQUASH
CUTCHOGUE
T100889261
OLD PASTURE RD
N CROSSRD
2735
285'
4' x~4' Bell Hole
PEQUASH AVE
O9
09
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