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HomeMy WebLinkAboutHolden Ave (2) f � * * * RECEIPT * * * Date: 08/13/13 Receipt#: 157537 Quantity Transactions Reference Subtotal 1 Excavation Permits 859 $209.90 Total Paid: $209.90 Notes: Payment Type Amount Paid By CASH $209.90 National, Grid -Gas Constr. Dept Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LYNDAR Internal ID:859 Permit No. 59 TOWN OF SOUTHOL) RECEIVED HIGHWAY DEPARTMENT File No. 859 Peconic Lane AUG 1 3 2013 Peconic,New York 11958 (631)765-3140 Southold Town Clerk APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR W.O.#T 101504929 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 Tvpe 1) NATIONAL GRID—GAS OPERATIONS DEPT.-175 E.OLD COUNTRY RD.—HICKSVILLE,NY 11801 Name of Applicant Address 2 Holden Ave. Cutchogue Owner of Premises 3) opening a-4'x4'x3' bellhole and a 1'x134'trench on the W/s of Holden Ave.,in the grass area of the road,atmrox. 158's/o North Cross Rd.,to install a gas service to#545 Eastwood Ave., Ext. 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 8-05-13 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 Comoletion Date Excavation......................................................................... Facility Installation............................................................... Backfill&Compaction......................................................... Pavement Replacement......................................................... 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: $ 11) Remarks: t � 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 134'trench fee And..30 ea.Ft.after 101 Is$209.90 Addtional Excavations same service @$10.00= No. B. Excavations 18"in depth or less: 0-100 l.f.=$10.00- l.f.@$0.10= Additional C. Excavations 18"in depth to 5' in depth: 0-100 If_ Additional If @$30+101 trench 3,940 D. Excavations 5'in depth and over: 0-100 I.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= $209.90 Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to: NATIONAL GRID in accordance with this application. SUPERINTENDENT OF HIGHWAYS TO"OF UTHC�D,NEW YORK w✓v Peter anis r , w ' Received by the Town Clerk Date�J S59 Date © o Permit Issued �S { g ,3. Permit No. 8 5 f Note: Permit expires one(1)year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways. Permit must be available for inspection. D-39 Page 2 of 3 Cony Distribution: Highway Department Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified I St 2nd 3rd 4th (To Permit Clerk) REMARKS CODE 113— Improper barricades IL — Improper lights ST — Sunken trench or excavation UTM — Unable to measure(due to backfilling) BUC — Building under Construction WIP — Work in Progress DB — Improper backfill(too high) (not sufficient) HFS — Inspector holding for final settlement of excavation RFR— Ready to Repair D-39 Page 3 of 3 JV -x,11.5 16:49 GAS SALE' PATCHOGUE 63175851 R2 P.C14 1 1Clt.iVi ici,t na REQUEST FOR STREET OPENING RERNIlT PC-Of 11.4 STATENASSAU SUFFOLK P COUNTY : COUNTY M!$ bB !Ca . ��c•�ev No: NO. LocAT10N ; 7 � .X43 ISL u� SLC _ REkso_NF OR. 0 G 14 ,X � 7 . cl dV 114 1fVC G�1 �. 71 .4 s f..fr..�✓, %� s��,.SSlS SAS 1wgc�d DATE QF a � c A w a a Z ? w/,moi-✓ �" -- _' � O z(sly TC!THL P. _+ 1