HomeMy WebLinkAbout1605 Old Shipyard LnPermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re~#TI00886861
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 thc 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 oftbe
job site.
Print or Type
I) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - H1CKSVILLE~ NY 11801
Name of Applicant
1605 Old Shipyard La.
Southold
Address
Owner of Premises Address
3)
4)
I-4'x4' bellhole on the E/s of Old Shipyard La. approx. 110' n/o Hobard Rd. to install a
gas service at #1605 Shipyard La.
s)
Builder's License No. ~ ///~t
Electrician's License No.
tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No. s t /~
Other Trade's License No. [~'///z'7
Signafure of AppliCant ~'
6-10-08
Date
5)
a) Atta~hp~~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) At~ach all other necessary permits and licenses for this project.
c) ~rkc~veredbythisapp~i~ati~nmayn~tc~mmencebef~rcissuance~faHighwayExcavationPermit
by the Town Clerk.
6) Tax Map: Section Block
7) Starting Date: Completion Date:
8) Work Schedule:
Lot
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 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
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for am}lications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.oo
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
L~ @ $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 l.f. = $50.00
L£ @ $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 lssued C [J,~!l~
'Date
Permit No. ~"(F) 8
SUPE~NDENT OF HIGHWAYS
o7 o7o<) o
Peter W. Harris
' / Date '
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
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Pe,~nit 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
W1P - 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
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W,OJPA
NO,
REQUESTED
BY
APPROVED
SKETCH
REQUEST FOR STREET OPENING PERMIT
~-~STATE ~ NASSAU
COUNTY ~ SUFFOLKcouNTY
FOREMAN
DEPARTMENT
GAS CONSTR, MAINT. & SERVICES
MIS JOB
NO..~ 0 ~::~ ~/ DATE~/,.~/~ ,~
'DATE OF
OPENING
DATE
N
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/18/08
* * * RECEIPT * * *
ReceiptS: 22263
Transaction(s):
1
Permits
Reference Subtotal
568 $170.00
Check#: 15292
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 568