HomeMy WebLinkAbout307 Wendy Dr 1 �
* * * RECEIPT * * *
Date: 09/30/13 Receipt#: 158822
Quantity Transactions Reference Subtotal
1 Excavation Permits 873 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#25840 $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: 873
' 09127/2013 13:20 5165454474 NGRID PAGE 02102
Permit TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT RECEIVED
_ File Pio. Peconic Lane
Peconic,New York 11958
(631)765-3140J P I j
APPLICATION/PERMIT FOR HIGHWAY EXCAVATJON AND REPAIR
Southold Town Clerk
W.0, T101506592
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town or Southold for the issuance or
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southo[tl,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 ofthe
job site.
Print or Type
1) NATIONAL G_Rzn—CAS CONSTR DEPT —125E OLD COUNTRY RD HICKSVILLE NY 11801
Name of Applicant Address
2) 307 Wendy Dr. Laurel Premises Address
3)
4) open a-4'x4'3 bellhole on the E/s of Wendy Ave. 265'W/o Peconic Bay Blvd.,to install a
gas service.
5)
6)
7) tidal wetlands? *Yea No X
*]f ycs,other Town permits may be required.
Builder's License No._ Plumber's License No.
Electrician's License No. Other Trade's/License No. / II
�1 -- -.1111
Sigeature of Applicant
Date;?Pill3
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 Cleric.
6) Tax Map: Section Block Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phage om .letion Datg
.
Excavation. ..................
Pacillty Installation...............................................................
Ilackirll&Compaction..................................
Pavement Replacement.....................................
9) Under which authority is the application made;
10) Estimated Cost or Proposed Work: S
11) Remarks:
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$50,000 property damage.
13) Securi :
a) Surety Bond or Certified Check provided in the total amount
of$
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications andpen-nits: Basic ADDlication 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 If. @.30=
D. Excavations 5'in depth and over:
0-100 l.f._$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:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUP "NDENTOFS
TO N K
Received by the Town Clerk 9 -13
Date
/� Date 7J
Permit Issued �9— .3 O /.�J V 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
i
Inspector
Applicant
Town Clerk
INSPECTOR`S RECORD
Inspection Date Findings(use code) Applicant Notified
2 n
3rd
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
Page 3 of 3
D-39
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DATE: 9119/2013
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LOCATIC[d: 305 WENDY DR CROSS STREET I: Pecornc Bay Blvd �
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