HomeMy WebLinkAbout410 Jackson StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/09/08
* * * RECEIPT * * *
ReceiptW: 21235
Transaction(s):
1 1
Permits
Reference Subtotal
564 $170.00
Check#: 15240
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 564
Permit No.
File No.
TOWN OF SOUTHOLD R
HIGHWAY DEPARTMENT
Peeonie Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPA~I~Bi~01{I '[OWfl Cle/~ ~ y'
Re£#T100885705
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 Address
2) 410 Jackson Street
New Suffolk Owner of Premises Address
3) 1-4'x4' bellhole on the S/s of Jackson St, 600' e/o Kimogenor Pt. Rd. to install a t, aa
service
4) tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No. Plumber's License No.
Electrician's License No.
s)
Other Trade's License No.
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 ora Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
FaciIRy Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
., Lot
Completion Date
12) Insurance Coverage (Attach Copy)
a) Insurance Company:
b) Policy g
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 Injury, 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 annlicafions and vermits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$20.oo
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
1.£. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional 1£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 I.f. = $50.oo
l.t. @ $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 ~ - ~' OZ~g'
Permitlssued ~ ~ f O~ Date
· - Permit No.
SUPER~R~)NDENT OF HI.~IWAYS
TOW~ OF~UT~LO,~W YORK
Peter W. H~is
Z ~te
Note: Permit expires one ( 1 ) year fi.om Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
3rd
4th
Findings(usecode)
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- Inspectorholdingforfinalsettlementofexcavation
RFR - Ready to Repair
D~39 Page 3 of 3
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Village Of
6/2/2008
410JACKSON ST
NEW SUFFOLK
T100885705
(~-~OSS S'FR.EET 1:
CROSS SI'R.K~T 2.'
KIMOGENOR PT RD
KIMOGENOR POINT RD
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Ze 600'
4' II Hole
JACKSON ST