HomeMy WebLinkAbout360 Cleaves Point Rd S �
* * * RECEIPT * * *
Date: 02/26/14 Receipt#: 165043
Quantity Transactions Reference Subtotal
1 Excavation Permits 907 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#26830 $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:907
Permit No. TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic,New York 11958 FEB 2 4 � I4
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATTON AND REPAIR Southold Town Clerk
W.0,T101571596
APPLICATION L9 HEREBY made to the Superintendent of Highways of the Town of Southold for the Issuance of
Ad Excavation Permit pursuant to Chapter e.3 of the Code of the Town of Southold.Suffolk County,Now York,and other
applicable Isms,ordinances or reguladons for the excavation hereln described. The applicant agrees to comply with all
applicable laws,ordlunces,codes and regulations,and to permit authorized iospoclors to make necessary Inspections of the
job site.
Print or Tvoe
1) KEYSPAN GAS EAST CORPORATION d/bta NATIONAL GRID-GAS CONSTR. DEPT. -175 F OLD
COUNTRY RD.-TlKXSVTLI,E,NY 11801
Name of Applicant Address
2) 360 Cleaves Point Rd. E.mcdon Prcmisea Address
3)
4) Open a-41x4'bellhole on the N/a of the road,approx.80'W/o E Gillette Dr.,to install a
gas service.
5)
6)
7) tidal wetlands? *Yes No_X
*If yes,other Town pernalts may be required.
Bullder's,License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
Signature of Applicant
Date,al 1114
S) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areae,and giving a detailed description of layout of excavation.
b) Attach all other necessary permits and licenses for this project
e) Work covered by this application may not commence before issua see of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section ,Block ,Lot
7) Starting Date. Completion Date:
8) Work Schedule:
Phase Completion Date
Excavad6a.................................... ..............................
Facility Installation...............................................................
Backfill&Compaction.......................................................
Pavement Replacement.........................................................
9) Under which authority is the application made,
10) Estimated Cost of Proposed Work: S
11) Remarks:
12) Insurance Q=990(Attach Copy)
900'd GT991P QI2iJ 'IVNOIIVN 86:9T tT03-TT-821.3
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:
0-1001.f._$10.00-
l.f.@$0.10=
Additional
C. Excavations 18"in depth to 5' in depth:
0-100 l.f._
Additional lf. @.30=
D. Excavations 5'in depth and over:
0-100 11_$50.00
I.f.@$0.50=$
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 Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTDE OIG AYS
YOTOWN OF RK
Vincent M.Orlando
4 1`�
Date
Received by the Town Clerk
Date
Permit Issued 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
god
3rd
4th
(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
nationalgrid
a PERMIT APPLICATION SKETCH o
Village Of
DATE: 2/11/2014 dd
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LOCATION: 360 CLEAVES POINT€Qss srREET I: E GILLETTE DR
U
T OWN: E MARION CROSS srREET z: GILLETTE DR
WORK ORDER: T101571596 0
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