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HomeMy WebLinkAbout1555 Village Ln (2) Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 01/29/13 Receipt#: 146090 Transaction(s): Reference Subtotal 1 1 Excavation Permits 811 $170.00 Check#: 23932 Total Paid: $170.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 811 oyFf 0.Y IF Permit No. 'TOWN OF SOUTHOLD HIGHWAY DEPARTMENT RECEIVED File No. Peconic Lane Peconic,New York 11958 (631)765-3140 JAN Z L APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Southold Town Clerk W.O.7101432276 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 ofthe 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 COU AddressYRD.-HICKSVILLE NY 11801 Name of Applicant 2) 1555 Village La. Orient Premises Address 3) 4) open a-4'x4'3 bellhole on the N/s of Village La.,approx. 230' s/o Orchard St.,to install a gas service. 5) 6) 7) 8) tidal wetlands' *Yes--,—, No_X_ *If ves,other Town permits may be required. Builder's License No. Plumber's License No. Electrician's License No. _ Other Trade's License No. 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 ma} 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......................................................... - -- - Pavemen(Replacement.........................................................- -- - 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: x 11) Remarks: — 12) InsuranceCo�Lt _,c(Attach ('opy) 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$50,000 property damage. 13) SeCUrit a) Surety Bond or Certified Check provided in the total amount of$ b) Maintenance Bonded provided: 2 years or ______3years 14) Fees for applications and permits: Basic Application Fee $150.00 A I. 1 /Service Connections excavations(a'; = $20.00 A2. /Additional Excavations same service(a.S 10.00 No. B. Excavations 18" in depth or less: 0-100 Lf._$10.00- ---- 1.f. (a)$0.10- Additional C. Excavations 18" in depth to 5' in depth: 0-100 1.f. Additional If. Vii!.30- D. Excavations 5' in depth and over: 0-100 Lf._$50.00 Lf. (c$0.50=S Additional E. Utility Repair Excavations(a $10.00=$ No. _ Repairs same service(a S5.00=_$ 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 IOMI of Southold to issue a Highway Excavation Permit to: KEYSPAN ENERGY DELIVERY in accordance with this application. SUPERINTENDENT OF HIGHWAYS TOW OF OUTHOLD,N W YORK Peter W. Harris -- --,�) �� -/"T� --- �� �3 Received b_v the Town Clerk Date Permit Issued �— oT/�'- /� Date Permit No. �fitl Note: Permit expires one(1)year from Date ol'I15nanCC. 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 Copv_Distribulion: Highway Department Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified I It 2nd 3'd 4d, (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 J HI I-�S-�bl3 bti 74 UHb bHLtb t'H l l,MUUUt b 51(JEi51ti� t .Ob nationalgrid RASH REQUEST FOR STREET OPENING PERMIT nNASSAU SUFFOLK Fc.6i11.4 STATE LJ ' 'COUNTY L_.J COUNTY P MIT .MIS JOB. DATE. Ngyp• O. .. 7� LacATIorl f o j s„�lwg A✓tel flEkS.ON FOR. . OPENING JAW , P�4 x a30 S D ©. Lfla� S GG ,� s 4lJi 'DATE OF - OI:+EIVINQ �s�. o ! o d �1 -� WOE r