HomeMy WebLinkAbout55 Middle Country Rd Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/20/11 Receipt#: 106833
Transaction(s): Reference Subtotal
1 1 Permits 715 $170.00
K#: 20978 Total Paid: $170.00
Name: National, Grid -Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Internal ID: 715
Clerk ID: LYNDAR
Permit No. TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic,New York 11958 JUN 2 O
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ou!"a oMfJwin Clerl
W.O.#T101242887
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) 55 Middle Country Rd. Mattituck Owners of Premises Address
3) 1-4'x4' bellhole on the E/s of Cox Neck Rd., 130' n/o Sound 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.
Signature of Applic t J
6-15-11
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 Coverage(Attach Copy)
r 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
A]. _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 Lf._$10.00-
I.f. @$0.10
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.=$50.00
Lf Ca?$0.50=$
Additional
v
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.
SUPERINTENDENT OF HIGHWAYS
TOW OF OU LD,NEW YORK
Peter W. Harris
/_ Date
Received by the Town Clerk (0-aO—�I
Date
Permit Issued �p - Q0— Ll Permit No. �5
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
I s'
2`1
3`1
4t"
(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
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