HomeMy WebLinkAbout980 Southern Cross Rd z
* * * RECEIPT * * *
Date: 06/02/14 Receipt#: 171121
Quantity Transactions Reference Subtotal
1 Excavation Permits 936 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#27842 $170.00 National, Grid - Gas Constr.
Dept
Name: National, Grid -Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 936
Permit No. TOWN OF SOUTHOLD
9 -W HIGHWAY DEPARTMENT
File No. Peconic Lane
Pecollic,New York 11958
(631)76:5.3140
APPLTCATTON/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.Q.T)0160707$
APPLICATION IS HEREBY made to the Superintendent of Higimays of the Town of SoutAold for the izanaace of
an Excaivxtion 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 ltws,ordinances,codes and regulatiom and to permit authorized inspectors to make accessary inspections of the
job site.
Print or DMe
1) KEYSPAN GAS EAST CORPORATION d/b/a NATIONAL GRM--(SAS COMTR. DEPT. -175 E.OLD
CQTZN=RD.-HICKSVTLLEa WC l I80t
Name of Applicant Address
Z) 980 Southern Cross Rd Cutchogue Premises Address
3) RECEIVE®
4) Open a-4'x4'bellhole on the s/s of Holden Ave,approx.95'W/o Southern Cross Rd,to
install a gas service to#f 980 Southern Cross Rd.
15)6)
JUN =)14
7) tidal wetlands? *Yes No_X_
*If ym,other Town permits way berequired. Southold Town Clerk
Builder's License No. Plumber's License No.
Electrician's License No. Other Track's License No.
A�4 " //r#_ .--
Signature of Ap plicant
Date;051
5) a) Attach plot plan showing locution 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) 'T'ax Map: Section ,$lock ,Lot
7) Starting Date: __ Completion Date:
8) Work Sebeduk:
PhPh ase C�omnlett_o�D�te
Excavation........................................I.......I........................ _
Facility Installa ............................................................
RocktID&Compaction........................................................
PavementReplacement......................................................... --
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: S
11) Remarks:
12) Ina=se ver U(Attach Copy)
300'd 6S99t, (IIHE) 'IbNOIIVN L9:IT tT03-30--NIIP
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$50,000 property damage.
13) Securi :
a) Surety Bond or Certified Check provided in the total amount
of$
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. _1 /Service Connections excavations @$20.00= $20.00
A2. /Additional Excavations same service @$10.00=
No.
B. Excavations 18"in depth or less:
0-100 Lf._$10.00-
a g$0.10=
Additional
C. Excavations 18"in depth to 5'in depth:
0-100 Lf._
Additional if @.30=
D. Excavations 5'in depth and over:
0-100 Lf._$50.00
Lf.@$0.50=$
Additional
E. Utility Repair Excavations @$10.00=$
No.
Repairs same service @$5.00=$
Additional
F. 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 Excav ' n Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINT T I S
TOWN O , Y
incent .Orlando
Date
Received by the Town Clerk
Date q 3G
Permit Issued G - 2'. l y Permit No.
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 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR`S RECORD
Inspection Date Findings(use code) Applicant Notified
I St
2nd
3`d
4 t
(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 of excavation
RFR— Ready to Repair
D-39 Page 3 of 3
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