HomeMy WebLinkAbout365 Chablis Path t
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 03/25/13 Receipt#: 147790
Transaction(s): Reference Subtotal
1 1 Excavation Permits 825 $170.00
Check#: 24284 Total Paid: $170.00
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 825
PermitNo.
/ TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic,New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.T101455937
APPI,ICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
pursuant to Chapter 83 of the Code of the Town of Southold,Suffolk County,New York,and other
an Excavation Permit
herein described. Th
applicable laws,ordinances or regulations for the excavation e 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 CONSTR. DEPT. -175 E.OLD COUNTRY RD.-HICKSVILLE NY 11801
ss
Name of Applicant
2) 365 Chablis Path
Southold Premises Address
3)
4) open a-4'x4'3 bellhole on the W/s of Chablis Path,70' n/o Burgandy Ct.,to install a gas
service.
5)
6)
7) tidal wetlands? *Yes _ NO K
*If ves,other Town permits may be required.
Builder's License No. Plumber's License No.
Other Trade's License No.
Electrician's License No. /
Signature of Applicant
3-19-13
5) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
ing a detailed description of layout of excavation.
public streets or areas,and giv
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:
Completion Date
Phase
Excavation ........................................................................._
Facilitv Installation...............................................................
Backfill&Compaction.........................................................
Pavement KcplacemenL........................................................
-------
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $_
11) Remarks:
12) Insurance Coverai4c(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 S _
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. 1 /Service Connections excavations((U$20.00= $20.00
A2. /Additional Excavations same service 10.00=
No.
B. Excavations 18" in depth or less:
0-100 I.f._$10.00-
I.f. @so.10=
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f._
Additional If & .30=
D. Excavations 5- in depth and over:
0-100 Lf.=$50.00
Lf.(a,$0.50=$
Additional
E. Utility Repair Excavations C$10.00=$
No.
Repairs same service(cu,$5.00=$
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.
SUPERINTENDENT OF HIGHWAYS
TO0 SOUTHOLD,N W YORK
Peter W. Harris
13
Date
Received by the Town Clerk
Date
Permit Issued Permit No.
Note: Permit expires one(1)ycm from Date of ISsnancc. 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"
3d
4[h
(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
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PERMU ASMICATION SIETCH
Village Of
DATE: 3/1912013
LOCATICN: 365 CHABLIS PATH CROSS STREET is BURGANDY CT
TOWN: SOUTHOLD CROSS STREET 2: SOUNDVIEW AVE
WcRK ORDER: T101455937
SURFACE:
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