HomeMy WebLinkAbout1380 Hobart Rd * * * RECEIPT * * *
Date: 10/01/13 Receipt#: 158836
Quantity Transactions Reference Subtotal
1 Excavation Permits 874 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#25893 $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: 874
09/3012013 12:58 5165454474 NGRID (PAGE 02102
Permit No. TOWN OF SOUTHOL.D
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic,New York 11958 RECEIVED
(631)765-3140
APPLICA'LON/PE TT FOR I(GUW�XCAYATION AND R PAIR OCT 1 "J 13
W.O.T10 527461
Southold Town Clerk
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,Now York,and other
applicable laws,ordinances or regulations for the excavation herein described. The applicant carets 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 Tyo
1) NATIONAL GRID GAS CONSTR. DEPT —125 JE,OLD COUNTRY RD,—HICKSYILLE.NY 11801
Name of Applicant Address
2) 1380 Hobart Rd. Southold Premises Address
3)
4) open a-41x413 bellhole on the E/s of Hobart Rd. 240'S/o of Lhomnctedien Ln.,to install a
gas service.
S)
6)
7) tidal wetlands'! *Yes No X�
*If yes,other Town permits may be required.
BulldWs License No. Plumber's License No. _
Electrician's License No. Other Trade's License No,
Signature of Applicant
7/0C 6113
S) a) Attach plot plan showing location of proposed exesvatlon and relationship to adjoining premises or
public streets or ares,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.........................................................
PavementReplacement.................................................I.......
9) Under which authority Is the application made:
10) Estimated Cost of Proposed Work: S
11) Remarks:
12) Insurance C v e(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$50,000 property damage.
13) Securi :
a) Surety Bond or Certified Check
of$ provided in the total amount
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
A1. _1_/Service Connections excavations @$20.00= $ 00
$220.00.00
A2. /Additional Excavations same service @$10.00=
No.
B. Excavations 18"in depth or less:
0-100 Lf._$10.00-
l.f.@$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
l.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:
KEYS:AN ENERGY DELIVERY in accordance with this application.
SUPERI NDENT OF HIG AYS
TOW OF OUT LD,N YORK
eter W. Harris
Received by the Town Clerk
/ Date
Date
f(
Permit Issued _!� Permit No. " 7oV
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
3rd
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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PEIMM "MICATION SKETCH o
Village Of
DATE: 9/25/2013
LOCATION: 1380 HOBART RD CROSS STREET I: LHOMMEDIEU LN
T OWN: SOUTHOLD CROSS STREET 2: TERRYLN
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