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HomeMy WebLinkAbout605 Clark Rd t r Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 06/19/12 Receipt#: 135886 Transaction(s): Reference Subtotal 1 1 Excavation Permits 777 $170.00 Check#: 22869 Total Paid: $170.00 Name: National, Grid - Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 777 3 Permit No. TOWN OF SOUTHOLD RECEI $,y,fIXA'� HIGHWAY DEPARTMENT File No. Peconic Lane JUN 1 9 2012 Peconic,New York 11958 (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Southold Town Clerk W.O.#T101367110 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 CONSTR. DEPT. —175 E.OLD COUNTRY RD.—HICKSVILLE,NY 11801 Name of Applicant Address 2) 605 Clark Rd. Southold Owner of Premises Addres 3) open a-4'x4'3 bellhole on the E/s of Clark Rd.,469' s/o Soundview Ave.,to install a gas service. 4) 5) 6) 7) tidal wetlands? *Yes No_X *If yes,other Town permits may be required. Builder's License No. Plumber's License No. Electrician's License No. Other Trade's License No. aA,-k= '- Signature of Applicant 06-15-12 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 Coveraee(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. –1—/Service Connections excavations @$20.00= $20.00 A2. /Additional Excavations same service @$10.00= No. B. Excavations 18"in depth or less: 0-100Lf._$10.00- l.f. @so.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 Lf.=550.00 Lf. a,$0.50=$_ Additional E. Utility Repair Excavations @$10.00=$_ No. Repairs same service(i),$5.00=S 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 Highway Excavation Permit to: KEYSPAN ENERGY DELIVERY in accordance with this application. SUPERINTENDENT OF H1 HWAYS TOW1�� THOL W YORK Pe er W. Harris LAZj to Received by the Town Clerk � Date y Permit Issued tr '/�! '/ L _ Permit No. / ., 1 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 INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified 1 sr 2nd 3'd 4 t — – (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 O � N bA � nationalgrid PERIIM APMICATION SKETCH Village Of DATE: 6/15/2012 LOCATICN: 605 CLARK RD CROSS STREET I: SOUNDVIEW AVE T OWK: SOUTHOLD CROSS STREET 2: NORTH RD WORK ORDER: T101367110 as s 23 SURFACE: Macadam Poe d> TI°' Na < 605 _ w elf o z o C X a C U 469' E U 4' x 4' Bell Hole Y 3 U CLARK RD 3 a a� • a