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HomeMy WebLinkAbout245 Kimberly Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/26/13 Receipt#: 146848 Transaction(s): Reference Subtotal 1 1 Excavation Permits 816 $170.00 Check#: 24082 Total Paid: $170.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Internal ID: 816 Clerk ID: LINDAC Permit No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT RECEIVED File No. Peconic Lane Peconic,New York 11958 (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIRSoutholdTown Clerk W.O.T101445617 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) 245 Kimberly La. Southold Premises Address 3) 4) open a-4'x4'3 bellhole on the E/s of the road,approx.350' s/o Pine Neck Rd.,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. —z Signature of Applicant 2-21-13 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: 12) Insurance Coceraee(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 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 Lf.= Additional lf. g.30= D. Excavations 5' in depth and over: 0-100 Lf.=$50.00 Lf.@$0.50=$ Additional E. Utility Repair Excavations @$10.00=$ No. dditional Repairs same service @$5.00 A =$ 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 TO7 SOUTHOLD,N W YORK Peter W. arris Received by the:7�Clerk a / d Date Date Permit Issued Permit No.____ 0______ Note: Permit expires one(1)year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of l lighways. Permit must be available for inspection- Page 2 of 3 D-39 Co )y_Distribution: lli,�h��av Departmcnt Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified 15` 2nd 3rd 4m (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 s / :ifs 15 a r2 all 4 a � s N a ' � E NE K � �. - � •. _. y .may ��"o, w m v� «4 11, Wk Z _ c W RD � N GC R L off ' N PARISH DR _N imp Elf n 2 w dN�'V—