HomeMy WebLinkAboutBay Home Rd (2) * * * RECEIPT * * *
Date: 05/07/13 Receipt#: 149752
Quantity Transactions Reference Subtotal
1 Excavation Permits 837 $404.30
Total Paid: $404.30
Notes:
Payment Type Amount Paid By
CK#24661 $404.30 National, Grid -Gas Constr.
Dept
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 837
Permit No. TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. Peconic Lane RECEIVED
Peconic,New York 11958
(631)765-3140 MAY 7 2013
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Southold Town Clerk
W.O.#T101439421
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 Bay Home Rd. Southold Owner of Premises
3) opening 3-4'x5' bellholes and a 1'x372' trench and on Budd Pond Rd.—2-4'x5',4-4'x4' bellholes
and a 1'x410'trench to install a gas main and services.
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.
gature�cant
5-01-13
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:
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/S500,000 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(a��$20.00= +20.00 bellhole+30.00 for
trench fee 100'trench fee
And .30 ea. Ft.after 101
A trench=$200.00
A2. /Additional Excavations same service a $10.00=
No.
B. Excavations 18" in depth or less:
0-100 1.f=$10.00-
Lf x$0.10=
Additional
C. Excavations 18"in depth to 5' in depth:
0-100 If _
Additional If C�$30+101 trench 782'
D. Excavations 5' in depth and over:
0-100 I.f.=$50.00
$30.00_1.f. @$0.50=$_
Additional
E. Utility Repair Excavations $10.00=$
No.
_ Repairs same service(u,$5.00=$
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST= $404.30
Authorization is hereby granted to the Fown Clerk of the Town of Southold to issue a Highway Excavation Permit to:
NATIONAL GRID in accordance with this application.
SUPEy4kTENDENT OF HIGHWAYS
TOW O SOUTHOLD, EW YORK
Peter W. Harris
Date
Received by the Town Clerk 7 ��
�{
Permit Issued 1 (J Date Permit No. `�' 3 7
Note: Permit expires one(1)year from Datc of Issuance. No work to start without 48 hour notice to the Superintendent of i lighways.
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
1St
Yd
4th
(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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