HomeMy WebLinkAbout45 Booth Pl Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 04/12/12 Receipt#: 129785
Transaction(s): Reference Subtotal
1 1 Excavation Permits 763 $200.00
Check#: 22490 Total Paid: $200.00
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID:763
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Permit No. TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
File No. 0 Peconic Lane
Peconic,New York 11958 Z Lu1z
(631)765-3140
Southold Town Clerk
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref#T101343453
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 45 Booth Place Greenport Owner of Premises Address
3) Opening a 4'x 6' bellhole on the S/s of Wilmarth Ave at the northeast corner of Booth PI and a
1' x 100' trench on the E/s of Booth PI to install a gas 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.
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Signature of Applicant "
04-10-12
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) _1_11surance Coveracc: (Attach Copy)
a) Insurance Company:
b) Policy# --- - —
0 State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/S500,000 Bodily Injwy,and S50,000 property damage.
13) Security:
a) Surety Bond or Certified Check _ provided in the total amount
of$
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. /Service Connections excavations(rig S20.00= +20.00 bellhole+30.00 for
trench fee 2 bellholes
And ea. foot from
A trench—5200.00
A2. /Additional Excavations same service a)S 10.00
No.
B. Excavations 18" in depth or less:
0-100 l.f.—S 10.00-
I.f. @$O.I O=
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f.
Additional If(c�.30= of trench 100'
D. Excavations 5' in depth and over:
0-100 Lf._$50.00
_$30.00 I.f. (cr $0.50=$
Additional
E. Utility Repair Excavations a $10.00—$
Repairs same service Vii;55.00=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 Town of Southold to issue a I lighway Excavation Permit to:
NATIONAL GRID in accordance with this application.
PINDENT OF HIGHWAYS
UJ_
LD,NEW YORK
Peter W. Harris
�
tc
Received by the Town Jerk
Date ?�
Permit Issued Permit
Note: Permit expires one(1)year from Date of Issuance. No work to start without 4S hour notice to the Superintendent of'Highways.
Permit nuistbe available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date Findings(use code) Applicant Notified
st
,„d
3'd
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
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