HomeMy WebLinkAbout6695 New Suffolk RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/09/08
* * * RECEIPT * * *
Receipt~: 21227
Transaction(s):
1
Permits
Reference Subtotal
563 $170.00
Check#: 15190
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 563
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100883164" i~,~:a C~,dt
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. - HICKSVIL!,E_ NY 11801
Name of Applicant Address
2) 6695 New Suffolk Road
New Suffolk Owner of Premises Address
3) 1-4'x4' bellhole on the W/s of New Suffolk Rd. 252' n/o F~nnin2 Rd. to install a oas
service
4)
Builder's License No.
Electrician's License No.
tidal wetlands? *Yes No X
*lf yes, other Town permits may be required.
5)
Plumber's LicenseNo.
Other Trade's License No.
5-28-08
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 ,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: $
11) Remarks:
Lot
Completion Date
12) Insurance Coverage (Anach 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) SecuriV/:
a)
Bodily injury and property damage: $300,000/$500,000 Bodily lnjury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) ~lications and.permits: Basic Application Fee $150.00
Al. _l~/Service Connections excavations ~ $20.00 = $20.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
~.~ @ $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:
o-10o 1.£ = $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 ~, - ~ ~ ~9 t9~
Permit Issued ~9 - ~ Ot~ Date Permit No.
SUPERINTENDENT OF HIGHWAYS
x -- --~e~r wTH~s
Date
N0t¢: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pemtit must be available for inspection.
D-39
Page2of3
Cop,/Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3~d
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 backfiIling)
BUC Building under Construction
WIP - Work in Progress
DB - lmproperbackfill (too high) (not sufficient)
HFS Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
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PEP_MIT APPLICATION SKETCH
Village Of
5/28/2008
6695 NEW SUFFOLK ~ss ff~ ~,
NEW SUFFOLK c~oss s~ ~:
T100883164
FANNING RD
GEORGE RD
6695
252'
4' x~' Bell Hole
NEW SUFFOLK AV NS
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