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Home My WebLink About1980 Sigsbee Rd * * * RECEIPT * * * Date: 11/01/17 Receipt#: 229388 Quantity Transactions Reference Subtotal 1 Excavation Permits 1234 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#39655 $170.00 National, Grid -Gas Permits. Dept Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: National, Grid - Gas Permits. Dept 175 E Old Country Rd Bld3A1 Hicksville, NY 11801 Clerk ID: LYNDAR Internal ID. 1234 Permit No.J e N OF SOUTHOLD HIGHWAY Y DEPARTMENT �o�guFFa�,r�oG� Peconic Lane Peconic,New York 11958 y � � T102014366 (631)765-3140y�io1 , APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or regulations for each individual contiguous excavation project herein describdd. The applicant agrees to comply with all applicable laws, ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized inspectors to make necessary inspections of the job site. Print or 1:M Keyspan Gas East Corp D/B/A National Grid Gas Permits Dept. Bldg: 3 Fl: 1 1 516 545 4094 175 E. Old Country Rd Hicksville, NY 11801 Name of Applicant Phone Number Address of Applicant 2. Name of Contractor Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4 1980 SIGSBEE RD-W/S, 673' N/0 PECONIC BAY BLVD-MATTITUCK Work Description and Location(Street Number,Hamlet,Cross Street) (a) is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. Margaret Paglia &4kA44�� NOTE: All information requested by this Signature of Ap icant Application/Permit form Is Required-for a complete application! 10/20/17 Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of nll site and pavement restoration work. (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 No.: District ]000 , Section L Block Lot�-5 7. Starting Date: 11/20/17 Completion Date: 11/21/17 8. Work Schedule: Phnce Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill S Completion for consideration as a Pavement Replacement Complete Application. 9. Under which authority is application being made: Keyspan Gas East Corporation d/b/a National Grid See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost orProposed Work: $ – 11. Remarks: Open & restore (1) 4'x4' mac bell hole D-39 1 of 3 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: Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed: $1,000,000 per Occurrence and S 2,000,000 general aggregate., 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Applications and permits: Basic Application Fee for Each Project Location - $150.00 A Project Location would include each Bell Hole and/or every road opening or excavation within any 50'Radius whether or not they may be inter-connected by open trench or directional boring. The total number of Project Locations shall be subject to file approval of the Highway Superintendent. Al. /Service Connections excavations Q 520.00 S 20.00 No. A2. /Additional Excavations same service Q S 10.00 S No. B. Excavations 18"in depth or less 0-100 L.F.=$10.00;Additional L.F.Q$0.10 $ C. Excavations 18"in depth to 5' in depth 0-100 L.F.=$30.00;Additional L.F.®S0.30 S D. Excavations 5' in depth and over 0-100 L.F.=$50.00;Additional L.F.Q$0.50 $ E. Utility Repair Excavations Q$10.00 $ No. Repairs same service Q$5.00 $ Additional TOTALS 170.00 F. Notice to public utilities proof must be provided and Shall be attached to this application prior to issuance of permit. Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: in ccordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any attached hereto. SUPERINTENDS O V TOWN OF SOU 10 V K Vificent-976riandg � Date Date Received by the Town Clerk _q_11_.1__ Date Permit Issued Permit No. L -! NOTE: Permit expires one(1)year from date of issuance. No work to start without 24 hour notice to Superintendent of Highways, Permit must be available at all times for inspection,on site,during construction, D-39 2 of 3 Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 1st 2nd 3rd 4th (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 for Repair D-39 3 of 3 national grid N a PERMIT "MICATION SKETCH o Village Of L DATE: 10/1912017 LOCATION: 1980 SIGSBEE RD CROSS STREET 1: PECONIC BAY BLVD N T OWN: MATTITUCK CROSS STREET 2: MAIN RD wmK ORDER: T102014366 N SURFACE: Macadam Roe d> IIa„mNa � 1980 _ < Q < 2 o 00 ... U � O x WCL 673' ;L c� 4'x 4' Bell Hole U N N SIGSBEE RD - 3