HomeMy WebLinkAbout2155 Grand AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/03/08
* * * RECEIPT * * *
Receipt~: 12725
Transaction(s):
1 1
Permits
Reference Subtotal
545 $170.00
Check#: 10063
Total Paid: $17Q00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 545
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100848481
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) 2155 Grand Avenue Mattituck Owner of Premises Address
3) Grand Ave.- bellhole W/s of Grand Ave., 80' s/o Woodcliff Drive
4) 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 Li~ ~,~a~l
Signature of Applicant
2~64)8
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 Towr. Clerl~
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
., Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
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:
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
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for avvlications and permits: Basic Application Fee
Al. _l~/Service Connections excavations ~ $20.00 =
$150.00
$20.00
A2. /Additional Excavations same service @ $10.00 =
No.
B. Excavations 18"indepthorless:
0-100 I.£ = $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 l.f. = $50.00
1.£ ~ $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 Issued
Permit No. ,~q5
Peter W. lelarris
[ Dat~
Note: Permitexpiresone(l)year from Dateoflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTQR'S RECORD
Inspection Date
2rd
3rd
4th
Findings (use 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- inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
DATE~
LO~ATI(~q:
T OWN:
W~.K ORDER~
SUR~ACI~:
~acadam Ro~ d ~
P~RMIT APPLICATION SI~TCH
Village Of
2/26/2008
2155 GRAND AVE
MATTITUCK
T1008,48481
CROSS STI~]~T 1:
CROSS STI~I~T 2~
WOODCLIFF DR
MAPLE AVE
NO.
55
q..
4' ~4' Bell Hole
GRAND AVE
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