HomeMy WebLinkAbout1380 Grathwohl RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/26/07
* * * RECEIPT * * *
Receipt: 8467
Transaction(s):
1 1
Permits
Reference Subtotal
502 $170.00
Checldk 8467
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 502
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.#T100744~thO~d ]'~¥,'n Clerk
APPLICATION IS HEREBY made to the Superintendent of Highways of thc 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
i) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant Address
2) 1380 Grathwohl Rd. New Suffolk Owner of Premises Address
3) Grathwohl Rd. - bellhole on E/s 562' S/o George Road to install a gas service in front of
1380 Grathwohl Rd.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If ~es, other Town permits may be required.
4)Builder's Licensg No. ]~]/~/~' Plumber's License No. /~/]~/
Electrician's License No. ! ] / ' Other Trade's L' ense No. '
Signature
4-24-07
Date
5) a) Attachp~~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) AHach 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 , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
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 Covcranc (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) Seeuri~:
a)
Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$20.O0
A2. /Additional Excavations same service ~ $10.00 =
No.
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 =
646 Ft of Trench
D. Excavations 5' in depth and over:
0-100 l.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 ~?//~ 0~ //~'' 7
t.~g~ 0/0 Date
Permit Issued ~ Pe~it No.
SUPERINTENDENT OF HIGHWAYS
Note: Permit expires one (l) year from Dateoflssuance. Noworktostanwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2nd
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
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS Inspector holding for final settlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION ~KET~H
DATE:
LOCATION:
TOWN:
WOP, K C~DI~R:
4t24/2(~07 11:18:50 AM
1380 GRATHWHOL KD
NEWSUFFOLK
TI00744190
VILLAGE
~.OS S STREET: GEORGE RD
r~
Ho',~e NO.
1380
56~
/
4' x 4' Bell Ho~
GRATHWHOL RD