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HomeMy WebLinkAbout975 Oriole Dr Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 03/14/13 Receipt#: 147434 Transaction(s): Reference Subtotal 1 1 Excavation Permits 824 $170.00 Check#: 24126 Total Paid: $170.00 Name: National, Grid -Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID:824 . 0g3f01.Yq Permit No. TOWN OF SOUTHOLD RECEIV 4� HIGHWAY DEPARTMENT File No. Peconic Lane Peconic,New York 11958 (631)765-3140 Southold Town Clerk APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR W.O.T101439514 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 CONSTR. DEPT. —175 E.OLD COUNTRY RD.—HICKSVILLE NY 11801 Name of Applicant Address 2) 975 Oriole Dr. Southold Premises Address 3) 4) open a-4'x4'3 bellhole on the N/s of the road,approx.255' southeast of Lisa Dr.,to install a gas service. 5) 6) 7) tidal wetlands? *Yes No_X *If yes,other Town permits may be required. Builder's License No. Plumber's License No. Electrician's License No. Other Trade's License No. `JcIAA-1-1- : — Signature 9f Applicant 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: $ 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 and permits: Basic Application Fee $150.00 A1. _1_/Service Connections excavations @$20.00= $20.00 A2. /Additional Excavations same service @$10.00= No. B. Excavations 18"in depth or less: 0-100 Lf.=$10.00- I.f.@$0.10= Additional C. Excavations 18"in depth to 5' in depth: 0-100 I.f._ Additional lf. @.30= D. Excavations 5'in depth and over: 0-100 I.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. SUPERINTENDENT OF HIGHWAYS TO SOUTHOLD, EW YORK Peter W. Harris 1 Date Received by the Town Clerk Date Permit Issued 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 Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified I St 2nd 3 rd 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 FEB-20'2013 07:29 GAS SALES PATCHOGUE 6317585182 P.02 navonal%n .REQUEST FOR 3T`RE. TOPEmIIVG PERMIT n NASSAU S.UFPOLK FGBit 1.4 LJ STATE' a COt1N TY P El COUNTY M1S 40B LOCATION 9 7.5 .def©L� ,REAS.ON FOR. OPE41NO �ad : Lisa. �2. _ o. ��nISiAGL � DATE OF 001. OPENING . SHIP