HomeMy WebLinkAbout350 Eastwood Dr � t
* * * RECEIPT * * *
Date: 05/29/13 Receipt#: 151232
Quantity Transactions Reference Subtotal
1 Excavation Permits 846 $209.00
Total Paid: $209.00
Notes:
Payment Type Amount Paid By
CK#24815 $209.00 National, Grid -Gas Constr.
Dept
Name: National, Grid -Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 846
Permit No. TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic,New York 11958 MAY 7 S ZJ)3
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Southold Town Clerk
W.O.#T101471963
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
2 350 Eastwood Dr. Cutchogue Owner of Premises
3) opening a-4'x5' bellhole and a 1'x130' trench in the E/s paved area approx.218' southeast of
Midwood Rd.to install a gas main and service.
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
5-21-13
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: S
11) Remarks:
1 1
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 andpermits: Basic Application Fee $150.00
A]. /Service Connections excavations @$20.00= +20.00 bellhole+30.00 for
trench fee 100'trench fee
And..30 ea. Ft. after 101'
A trench=$209.00
A2. /Additional Excavations same service @$10.00=
No.
B. Excavations 18"in depth or less:
0-100 I.f.=$10.00-
I.f. Ga)$0.10=
Additional
C. Excavations 18"in depth to 5' in depth:
0-100 If —
Additional If @$30+101 trench 130'
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= $209.00
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.
SUPE
RIN ENT OF HIGHWAYS
TOWN TH LD,NE ORK
Peter W. Harris
Received by the Town Clerk F✓
Date
Permit Issued
"Fla 41 /� Permit
Note: Permit expires one(1)year from Date of Issuance. No work to start without 4R hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 o1`3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date Findings(use code) Applicant Notified
IA
2nd
3`d
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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