HomeMy WebLinkAbout201 Champlin Pl ' r
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 11/27/12 Receipt#: 143474
Transaction(s): Reference Subtotal
1 1 Excavation Permits 801 $200.57
Check#: 23611 Total Paid: $200.57
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 801
Permit No. 6� TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. Peconic Lane RECEIVED
Peconic,New York 11958
(631)765-3140
N 27
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.#T1014064UU1h0ld 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
2 201 Champlin Pl. Greenport Owner of Premises
3) Opening 2-4'x 6' bellholes and a 1'x120' trench on the S/s of the road approx.295' e/o Sterling
Pl.,to install a gas main and service
4) Work Description and Location(Street Number,Hamlet,Cross Sheet)
(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
10-25-12
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:
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: $300,000/$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
Al. _/Service Connections excavations CG;$20.00= +20.00 bellhole+30.00 for
trench fee 100' trench fee
And ea. foot from '
A2. /Additional Excavations same service cc A trench=$200.00$10.00=
No.
B. Excavations 18"in depth or less:
0-100 I.f._$10.00-
l.f. @so.10=
Additional
C. Excavations 18"in depth to 5' in depth:
0-100 I.f. =
Additional Ifav.30= of trench 120'=.57
D. Excavations 5' in depth and over:
0-100I.f. 550.00
_$30.00_Lf @$0.50=$
Additional
E. Utility Repair Excavations cu,$10.00=S
No. -
Repairs same service cu,S5.00=$
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST= $200.57
Authorization is hereby granted to the Town Clerk of the"town of Southold to issue a Highway Excavation Permit to:
NATIONAL GRID in accordance with this application.
SUP NDENT OF HIGHWAYS
TO NOF UTHOLD, NEW RK
%a
Peter W. Harris
//--22(, -1,)-
Received by the Town Clerk //' a2 7' /a2,
Date
Date
Permit Issued 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.
D-39
Page 2 of 3
s
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date Findings(use code) Applicant Notified
151
�nJ
Yd
41"
(To Permit Clerk)
REMARKS
CODE
113— 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
OCT-23-2012 11:42 GAS SALES PAT-H000E h317585182 P.03
nationaigrid
REQUEST FOR STREET OPENING PERMIT
NASSAU
Fcet>>,a ❑ STATE ❑ COUNTYSUFFOLK
❑. COUNTY oGck1
P IT C^1 D�t/ (c1
NO 108 JOB DATE LOCATION � G�✓
REASON FOR.
° INa / oil i1/c r ?
70LDATE OF :
4e,d-/a6--5-6-990 7 bFENlIVa �I�/1-f'
T �
Z
e �
3
i
IN
I�
ob
i
i
— M DP9
,Oc✓
ALA
TOTAL F.OZ,