HomeMy WebLinkAbout170 Chablis Path Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 146091
Date: 01/29/13
Reference Subtotal
Transaction(s):
1 1 Excavation Permits
812 $202.70
Check#: 23931 Total Paid: $202.70
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Internal ID 812
Clerk ID: LINDAC
off W
Permit No. TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. Peconic Lane RECEIVED
Peconic,New York 11958
(631)76_5-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR JE `'
W.O.#T101426 76 thOld Town Clerk
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 Tvpe
1) NATIONAL GRID—GAS OPERATIONS DEPT.—175 E.OLD COUNTRY RD.—HICKSVILLE NY
11801
Name of Applicant Address
2 170 Chadblis Path Southold Owner of Premises
3) opening-a-4'x 5' bellhole in the W/s intersection of Soundview Ave.and a 11x100' trench in the
W/s paved area 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_N
*If ves,other Town permits may be required.
4) Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
�z
Signature of Applicant
1-23-13
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.........................................................--
1'avement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work:
1 1) 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: S300,000/S500,000 Bodily Injury,and$50,000 property damage.
13) Security:
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. /Service Connections excavations(cu,$20.00= +20.00 bellhole+30.00 for
trench fee 100'trench fee
And ea. foot from
A trench=$200.00
A2. /Additional Excavations same service(4,S 10.00=
No.
B. Excavations I8" in depth or less:
0-100 I.f._$10.00-
1.f. C(i,$O.l 0=
Additional
C. Excavations 18"in depth to 5' in depth:
0-1001.f. _
Additional IfC4., .30= of trench 110'
D. Excavations 5' in depth and over:
0-100 l.f.=$50.00
$30.00 I.f. (c)$0.50=$
Additional
E. Utility Repair Excavations C%$10.00=S
No.
Repairs same service W $5.00=S
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST= $202.70
Authorization is hereby granted to the Town Clerk of the FOW1 of Southold to issue a Highway Excavation Permit to:
NATIONAL GRID in accordance with this application.
SU NDENTOF HIGHWAYS
TO NOF S UTHOLD, EW YORK
r - ,
Peter W. Harris
J ( j
Date
Received by the Town Clerk �- -� 3
Date
Permit Issued �' ��-�� Permit No. �
Note: Permit expires one(I)year floor Date of Issuance. No vcork to start kcithout 48 hour notice to the Superintendent of 1 hghways.
Permit mist be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTO R`S RECOR1)
Inspection Date Findings(use code) Applicant Notified
I St
2nd
3'd
(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- Rcadv to Repair
D_39 Page 3 of 3
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