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HomeMy WebLinkAbout165 Love Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 11/27/12 Receipt#: 143475 Transaction(s): Reference Subtotal 1 1 Excavation Permits 802 $200.00 Check#: 23628 Total Paid: $200.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 802 pFI Xxp Permit No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT RECEIVED File No. Peconic Lane Peconic,New York 11958 (631)765-3140 2 7 ^"1? APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 23thold Town Clerk W.O.#TI014114' APPLICATION IS HEREBY made tothe 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 2 165 Love La. Mattituck Owner of Premises 3) opening a-4'x 4' hellhole on the W/s of the road,approx. 175' s/o Pike St.+a 55'x V trench in the R.O.W.,to install a las 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 10-29-12 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: S 11) 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/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 andpermits: Basic Application Fee $150.00 A]. /Service Connections excavations(c,,,$20.00= +20.00 bellhole+30.00 for trench fee 100'trench fee And ea. foot from A2. /Additional Excavations same service cc,S 10.00= A trench=$200.00 No. B. Excavations 18"in depth or less: 0-100 l.f.=$10.00- l.f. @$0.10= Additional C. Excavations 18"in depth to 5' in depth: 0-100 If = Additional If Ca".30= of trench 50' D. Excavations 5' in depth and over: 0-100 I.f=$50.00 _$30.00_I.f. a,50.50 Additional E. _Utility Repair Excavations Cr 510.00=S No. _ Repairs same service Vii-S5.00=S 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 I own of Southold to issue a Highway Excavation Permit to: NATIONAL GRID in accordance with this application. SUPERINTENDENT OF HIGHWAYS TOWN-OF SOUTHOLD,NEW YORK Peter W. Harris ��--- Received by the Town Clerk_ �� 7– /'Z� Date Date w Permit Issued X Permit No. O Q Z" 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. 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 s` Yd 0' (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 OT-29-2012 ©6:C�7 GAS SGLE PgT,�HOGUE 6317565182 P.O- nationalgrid REQUEST FOR STREET OPENING PERMIT FC-6111.4 ❑ NASSAU a SUFFOLK STATE COUNTY COUNTY PERMIT MIS JOB NO. NO. DATE��/c��y4p/8- LOCATION ! , B6 14fvlE d.✓ TNS cd s Q¢ REASON FOR -r^ 1 � OPENING /tl� �Opd �+ X 75a 1'i�E.5��' inti DATE OF OPENING �S�-� LON I s * P 4'_2" r O � b M =� o ' TOTAL P.P7