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HomeMy WebLinkAbout570 Pinewood Rd Town of Southold P.O Box 1179 Southold, NY 11971 (631) 765-1800 RECEIPT #766 05/09/2012 National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Received $ 242.00 for Excavation Permits, on 05/08/2012. Thank you for stopping by the Treasurer's Office. As always, it is our pleasure to serve you. Elizabeth A. Neville Southold Town Clerk r-C 6�e Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT Date: 05/08/12 Receipt#: 131711 Transaction(s): Reference Subtotal 1 1 Excavation Permits 766 $170.00 Check#: 22640 Total Paid: $170.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 766 a RECE1 41 Permit No. 'TOWN OF SOUTHOLD HIGHWAY DEPARTMENT MAY 7 2012File No. Peconic Lane Peconic,New York 11958 (631)765-3140 Southold Town Clerk APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Ref#T101345009 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) 570 Pinewood Rd Cuthogue Owner of Premises Address 3) 1-4'x6' bellhole&240' trench on the w/s of Pinewood Rd—aoprox 114' n/o Southern Cross Rd to install a eas main& 2 eas services to 570&555 Pinewood Rd 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 5-2-12 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&C'ompaction......................................................... Pavement Replacement......................................................... 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: S 11) Remarks: M 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) Securi : 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(q)$20.00= +20.00 bellhole+30.00 for 100' trench fee And .30 ea. foot from 101' $99.00) A2. /Additional Excavations same service(a?$10.00= No. B. Excavations 18"in depth or less: 0-100 I.f._$10.00- 1.f. @$0.10= Additional C. Excavations 18"in depth to 5' in depth: 0-100 l.f. Additional If(a,'.30= of trench 130' D. Excavations 5' in depth and over: 0-100 I.f.=$50.00 l.f. @$0.50=$ Additional E. Utility Repair Excavations(hi$10.00=$ No. Repairs same service(ci;$5.00 $ Additional F. Notice to public utilities proof must be provided and attached to this application prior to issuance of permit. TOTAL COST= $242.00 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. SUP INTENDENT OF HIGHWAYS WN F SOUTH D,NEW YORK Peter . Harris �/ to Received by the Town Clerk �Z-- _ / Date Permit Issued- 5N- 1 �- 1-Z - Permit No. Nota. 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 60r inspection. 11)-39 Page 2 of 3 Copy Distribution: Highway Department Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified 1 sl 2nd 3rd 4th (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-34 Page 3 of 3 MAY-01-2012 11:46 GAS SALES PATCHOGUE 6317585182 P.08 r ,a t, rgrla REQUEST FOR 3TRLT'OPENINQ PERRMT -1 NASSAU SUFFOLK rcetis.a CJ STATE 17COUNTY C� COUNTY PERM u Laf N0. NC da� �. LOCATION. _ , RE/.4S.ON FOR. � OPENINQ Cess' o. i��A-1L ,�.r�i�;�✓� 0?.��2vicfs' oP6WINo 0 4 � � o o � d I I 1-1 sem` �1 I � c c (N .,s w I a TOTAL P.08