HomeMy WebLinkAbout315 Wicks RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/17/09
* * * RECEIPT * * *
Receipt~: 43415
Transaction(s):
1 I
Permits
Reference Subtotal
612 $170.00
Check~: 16827
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 612
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, Now York 11958
(631) 765-3140
RECEIVED
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
$oufholcl Town Clerk
Ref.#TI00997733
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
2) 315 Wicks Street
New Suffolk
Address
Owner of Premises Address
3) 1-4'x4' hellhole on the S/s of Wicks St, 200' w/o New Suffolk Rd., to install a gas service
4)
6) tidal wetlands? *Yes No
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other Trade's License~l~. ~
3-11-09
Date
a) AHach plot plan showing location of proposed excavation and relationship to adjoining premises or
publle streets or areas, and giving a detailed deseriptlon of layout of excavation.
b) Attach all other necessary permits and licenses for this projecL
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
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility InstaOation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
Il) Remarks:
, Lot
Completion Date
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
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$20.oo
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.~ = $50.oo
l.f. ~ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
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.
Received by the Town Clerk
Permit Issued ~[?'~0ti'' Date Permit No. ~'/'~2-~/
SUPERI~]~TENDENT OF HIGHWAYS
Peter W. Harris
/ Patti
Note: Permit expires one (I) 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
Cony Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3ra
Findings (use code)
Applicant Notified
(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- lnspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
nationalgrid
DATE:
L OCATI CPi':
T OWN:
WCI~.K OF. DEF.:
3/12/2009
315WICKS RD
NEW SUFFOLK
T100997733
PE~ APPLICATION SKETCH
Village Of
(~.05S ST F..E E T
CROSS STREET
NEW SUFFOLK RD
GRATHWOHL RD
315
200'
Bell Hole
]2
WICKS RD
,I