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HomeMy WebLinkAboutSound Dr & Greenhill Ln * * * RECEIPT * * * Date: 10/29/13 Receipt#: 159370 Quantity Transactions Reference Subtotal 1 Excavation Permits 884 $220.00 Total Paid: $220.00 Notes: Payment Type Amount Paid By CK#26123 $220.00 National, Grid - Gas Constr. Dept Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 884 Y #140 RECEIVED Permit No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT File No. Peconic Lane Peconic,New York 11958 (631)765-3140 Southold Town Clerk APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR W.O.#T101529405 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 OPERATIONS DEPT.—175 E.OLD COUNTRY RD.—HICKSVILLE,NY 11801 Name of Applicant Address 2 Sound Dr&Greenhill La. Greenport Owner of Premises 3) Opening 1-4'x4' and 1-4'x6'ovenine in the crass and 1'x55' trench in the crass and 1- 1'x45'trench in the macadam to install a aas main and service to#2000 Sound Dr. 4) Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No_X *If yes,other Town permits may be required. 4) Builder's License No. Plumber's License No. Electrician's License No. Other Trade's License No. Signature of Applicant 10-24-13 Date 5) 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 ,Lot 7) Starting Date: Completion Date: 8) Work Schedule: Phase Completion Date Excavation......................................................................... Facility Installation............................................................... Backfill&Compaction......................................................... Pavement Replacement......................................................... 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: $ 11) Remarks: D-39 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$50,000 property damage. 13) Security: a) Surety Bond or Certified Check provided in the total amount of$ b) Maintenance Bonded provided: 2 years or 3 years 14) Fees for applications and permits: Basic Application Fee $150.00 Al. /Service Connections excavations @$20.00= +20.00 bellhole+30.00 for trench fee I00'trench fee And..30 ea. Ft.atter 101 Is$200.00 Addtional Excavations same service @$10.00— No.2 bellholes B. Excavations 18"in depth or less: 0-100 1.f.=$10.00- I.f.@so.10= Additional C. Excavations 18"in depth to 5' in depth: 0-100 If= Additional If @$30+101 trench D. Excavations 5' in depth and over: 0-100 l.f._$50.00 _$30.00_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= $220.00 Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Pennit to: NATIONAL GRID in accordance with this application. SUPERINTENDENT OF HIGHWAYS TOW UTHOLD,NEW f)ORK e er W. Harris 161--"2 �'- ' Date Received by the Town Clerk O— °Z y— �Jl Date �� Permit Issued �0 �°Z�—/3 Permit No. t��� Note: Pennit 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 sc 2nd 3 rd 4th (To Permit Clerk) REMARKS CODE 113— 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 X09: 14 P.Gni N A'T D/q A L &PU D REQUEST FOR STREET OPENING PERMIT NASSAU SUFFOLK FC-61 i 1.4 STATE COUNTY COUNTY m �a9(JTl�QL17 PERMIT NO. NO* JOB / !�/��� �� DATE�O .2.( LOCATION �� /o�����`•�L /4• !! U&PC3 ` �Q,C,C,q o� REASON FOR OPENING W.O./PA FOREMAN DATE OF NO. -- OPENING REQUESTED © DEPARTMENT DIVISION BY /�EN�I,E/t GAS CONSTR. MAINT. & SERVICES oh st )C�ra Lic APPROVED DATE SKETCH N r SouAiD Deu V6 . 7---, xGRASS OAD CROssiA16 68 6UHI L L LAnrr. TOTHL P. -F