HomeMy WebLinkAbout975 Moores Ln N Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/21/12 Receipt#: 143927
Transaction(s): Reference Subtotal
1 1 Excavation Permits 807 $170.00
Check#: 23776 Total Paid: $170.00
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 807
Permit No. TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. Peconic Lane RECEIVED
Peconic,New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 5S2 ��hh
W.O.T101427g'Id 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 CONSTR. DEPT. —175 E.OLD COUNTRY RD.—HICKSVILLE NY 11801
Name of Applicant Address
2) 975 Moores La.N. Greenport Owner of Premises Address
3)
4) open a-4'x4'3 bellhole on the W/s of Moore's La. North,262' s/o Inlet Pond Rd.,to install
a gas service.
5)
6)
7)
8) tidal wetlands? *Yes No_N
If yes,other Town permits map he required.
Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
Signature of Applicant
12-17-12
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: $
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: 5300,000/$500,000 Bodily Injury,and$50,000 property damage.
13) Security:
a) Surety Bond----or Certified Check provided in the total amount
of$
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
A 1. _1 /Service Connections excavations(i;520.00= $20.00
A2. /Additional Excavations same service(a $10.00 =
No.
B. Excavations 18"in depth or less:
0-100 I.f=S 10.00-
I.f (n�$0.10
Additional
C. Excavations 18"in depth to 5' in depth:
0-100 Lf. _
Additional If (�.30
D. Excavations 5' in depth and over:
0-100 I.f.—$50.00
I.f. @S0.50=$
Additional
E. _Utility Repair Excavations(c�$10.00=S
No.
Repairs same service(ts$5.00=$
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 I lighway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
Towt�OF)OUTHOLD,N W YORK
`" .
Peter W. Harris
C� J
Received by the Town Clerk 0�/ Date
Z �OPermit Issued Date�- O��• � Permit No. 7
Note: Permit expires one(1)year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of llighways.
Permit must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTO R`S RECORD
Inspection Date Findings(use code) Applicant Notified
I"
31
41"
(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
o
v
natio al r
PERAM APMICATION SKETCH
Village Of
DATE: 12116/2012
LOCATICN: 975 MOORES LN N CROSS STREET is INLET POND RD
TOWN: GREENPORT CROSS STREET HOMESTEAD WAY
waRK ORDER: T101427056
U_
N'
SURFACE:
Macadam Ra dHouse
Na C
975 p
< 0 >
LU
U w
W J p
0
CLX
a.
262'
C
4' x 4' Bell Hale
b
0
U
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N MOORES LN
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c
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