HomeMy WebLinkAbout550 Legion Ave ' Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 01/03/13 Receipt#: 144644
Transaction(s): Reference Subtotal
1 1 Excavation Permits 810 $200.00
Check#: 23821 Total Paid: $200.00
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Internal IU 810
Clerk ID: LINDAC
1 OH�1�2
Permit No. TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
' File No. Peconic Lane
Peconic,New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Southold Town Clerk
W.O.#T101429270
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 OPERATIONS DEPT.— 175 E.OLD COUNTRY RD.—HICKSVILLE,NY
11801
Name of Applicant Address
2 550 Legion Ave. Mattituck Owner of Premises
3) openine a-4'x 5' bellhole and a 1'x75' trench in the N/s of the road,approx. 500' w/o Pacific St,
to install a eas 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—X
*If yes,other Town permits may be required.
4) Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
Signature of Applicant
12-26-12
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: $
Il) 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: 5300,000/$500,000 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
A]. /Service Connections excavations cg$20.00= +20.00 bellhole+30.00 for
trench fee 100'trench fee
And ca. foot from
A2. /Additional Excavations same service aA trench=$200.00,S 10.00=
No.
B. Excavations 18"in depth or less:
0-100 I.f.=$10.00-
I.
2 50.10=
Additional
C. Excavations 18"in depth to 5' in depth:
0-100 I.f. =
Additional If @u.30= of trench 50'
D. Excavations 5' in depth and over:
0-100 Lf.=$50.00
_$30.00_Lf. @�,,$0.50=S _
Additional
E. Utility Repair Excavations Cc,,$10.00=$
No.
Repairs same service Ccu,55.00=$
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST= $200.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a f lighway Excavation Permit to:
NATIONAL GRID in accordance with this application.
SU RI TENDENTOFHIGf4WAYS
T' WN SOU HOLD, YORK
`Peter W. Harris
��, ��
Received by the Town Clerk Date
Date
Permit Issued 3 _�� 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.
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Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
IN'S PECTOR`S RECORD
Inspection Date Findings(use code) Applicant Notified
I"
,nd
Yd
aa,
(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
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