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Home My WebLink About1495 Founders Path ` Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/09/12 Receipt#: 125749 Transaction(s): Reference Subtotal 1 1 Excavation Permits 750 $170.00 Check#: 22206 Total Paid: $170.00 Name: National, Grid -Gas Constr. Dept 175 E Old Country Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID:750 y„rux� Permit No. TOWN OF SOUTHOLD `' HIGHWAY DEPARTMENT File No. Peconic Lane Peconic,New York 11958 (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR s ,.. " s !r ., �• , W.O.#T101325361 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) 1495 Founders Path Southold Owner of Premises Address 3) 1-4'x4' bellhole on the W/s of Founders Path,275' n/o Old Shipyard La.,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. Signature of Applicant T 02-07-12 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......................................................................... FacilityInstallation............................................................... Backfill&Compaction......................................................... PavementReplacement......................................................... 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: $ Il) Remarks: 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. _1_/Service Connections excavations @$20.00= $20.00 A2. /Additional Excavations same service @$10.00= 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 I.f._ Additional If. @.30= D. Excavations 5'in depth and over: 0-100 l.f._$50.00 l.f.@$0.50=$ Additional E. Utility Repair Excavations @$10.00=$ No. Repairs same service @$5.00=$ 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. SUP ENDENT OF HIGHWAYS T O SOUTHOLD�NEW�YRK E Peter W.Harris Received by the Town Clerk A//L Date Date Permit Issued 1 `� Z/ 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 Copy Distribution: Highway Department Inspector Applicant Town Clerk INSPECTOR'S RECORD Inspection Date Findings(use code) Applicant Notified 1 St 2nd 3rd 4 t (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 infationalgrid CIA On PER Ur "MICATION SKETCH o Village Of Ln 7t 0 DATE: 2/7/2012 LOCATICIY: 1495 FOUNDERS PATd,ioss STREET is OLD SHIPYARD LN T awry: SOUTHOLD CROSS STREET s: LANDON LN M WORK ORDER: T101325361 a 7t, 0 c� SURFACE: �X Macadam Poe Houm NO. Q 1495 o F J O CL E U 275' 3 4' x 4' Bell Hole U QJ N FOUNDERS PATH 443 �. a. 3 07/02 ' 12 TUE 15: 47 FAX 631 765 6145 SOUTHOLD TOWN CLERK TX REPORT TRANSMISSION OK TX/RX NO 1969 CONNECTION TEL 15165454474 CONNECTION ID ST. TIME 07/02 15: 45 USAGE T 02 40 PGS. SENT 10 RESULT OK Fat ELIZABETiEi A. NEViLLE 'r Town Hall,53095 Main Road ' P.O. Box 1179 TOWN CLERK a Southold New York 11971 RPGISTRnR OF VITAL STATISTICS 14 i� � ,A Fax (631) 765-6145 nLARR1Acr.OFFICER Telephone (631) 765-1800 RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FAX TRANSMITTAL Attn: Linda To. National Grid From: Linda J. Cooper, Deputy Town Clerk Dated: February 7,2012 Re: Highway Excavation Permits Number of Pages (including cover): 9 If total transmittal is not received, please call 631-765-1800, Ext 210 COMMENTS: Please accept my sincere apologies for the delay in getting these 4 permits to you. I received them on late Friday, January 27 and by the time Mondav rolled around they were hilrie'l nniipr ELIZABETH A. NEVILLE Town Hall, 53095 Main Road TOWN CLERK 5 P.O. Box 1179 yam, REGISTRAR OF VITAL STATISTICS °� Southold, New York 11971 MARRIAGE OFFICER Fax (631) 765-6145 I ew- "tx'� RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FAX TRANSMITTAL Attn: Linda To: National Grid From: Linda J. Cooper, Deputy Town Clerk Dated: February 7, 2012 Re: Highway Excavation Permits Number of Pages (including cover): 9 If total transmittal is not received, please call 631-765-1800, Ext 210 COMMENTS: Please accept my sincere apologies for the delay in getting these 4 permits to you. I received them on late Friday, January 27 and by the time Monday rolled around they were buried under work that come in from the weekend. Normally I try to get them out the same day the come in from the highway dept.