HomeMy WebLinkAbout885 Wickham AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/22~08
* * * RECEIPT * * *
Receipt~: 19387
Transaction(s):
1 1
Permits
Reference Subtotal
554 $170.00
Check#: 15085
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Cept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 554
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAI~,
Ref.#T100877198
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 Yorl~ 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
I) NATIONAL GRID - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant
2) 885Wickham Ave. Mattituck
Address
Owner of Premises Address
3) 1-4'x4' bellhole on the W/s of Wickham Ave. approx. 200' s/o Middle Rd.~ to retire a gas
service.
4) tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
Plumber's License No. ] //~-0
Other Trade's License No.
5-15-08
Date
5) a) Atta~hp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
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
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) 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:
13) Security:
a)
b)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for at~olications and permits: Basic Application Fee
Al. _l__/Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.00
B. Excavations 18" in depth or less:
0-100 I.£ $10.00-
I.£ ~ $0.10=
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.£ @ $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.
SUPERINTENDENT OF HIGHWAYS
TO~UTHOLD, NF~X/O ~
'P'e(er W. H~m'is
Received by the Town Clerk
Permit Issued ~.4'-~ ~ ~ ' O~[ Date
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
Page2of3
Cop,,, Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1~t
3~
4th
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB 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- lnspectorholding for final settlement ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
MAY-O?-2008 10:04 KEYSPAN GAS CONSTR 631 ?58 5136 P.O~
KEYSPAN
REQUESTFORSTREETOPENING PERMIT
n-"~. i---i NASSAU ~ SUFFOLK 1'--71 _.,,."' . /,,-.,
FC_,.em.4 I I STATE I l, COUNTY I I COUNTY
PERMIT MIS JOB DATE
.o. [ I.o..~~/~
FOREMAN
DEPARTMENT
[GAS CONSTR. MAINT.& SERVICES
IDATE OF
W.OJPA
NO.
REQUESTED
BY
APPROVED
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/22/08
* * * RECEIPT * * *
Receipt#: 19390
Transaction(s):
1 1
Permits
Reference Subtotal
555 $170.00
Check#: 15084
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Cept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 555
Permit No.
File No.
55¢
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#TI00876608
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 CONSTIL DEPT. - 175 E. OLD COUNTRY RD. - HICKSVII J~E_ NY 11801
Name of Applicant Address
2) 885 Wickham Ave. Mattituck Owner of Premises Address
3) 1-4'x4' bellhole on the W/s of Wickham Ave. approx. 162' s/o Middle Rd. to retire a gas
service.
4) tidalwetlands? *Yes No X
*if yes, other Town permits may be required.
Builder's License No.
Electrician's License No.
s)
Plumber's License No.
Other Trade's License~.~ ~N°'~~ _ ~
Signatur
5-15-08
Date
a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandre~ati~nshipt~adj~iningpremises~r
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) TaxMap: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
!1) 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:
13) Security:
a)
b)
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
ors
Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: Basic Application Fee
Al. _i~/Service Connections excavations ~ $20.00 =
A2. /Additional Excavations same service ~ $10.00 =
No.
$150.00
$20.oo
B. Excavations 18" in depth or less:
0-100 I.fi = $10.00 -
I.£ ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.£ =
Additional 1£ ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
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 ~q% O,/~ Ot~
Date ~.~ ~,N~
Permit Issued ~' ~&~ Pe~it No.
SUP~JI-gN-~NDENT OF HIGHWAYS
OF~UTHOLD, N~,~JOV YORK
Peter W. Harris
/ Dale
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
Page2of3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
3r~
4th
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 -lmproper backfill (too high) (not sufficient)
HFS- lnspector holding for final settlcment ofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
KEYSPAN ·
REQUEST FOR STREET OPENING PERMIT
W.OJPA
NO.
REQUESTED
BY
APPROVED
FOREMAN ' DATE OF
DEP^aTMENT =v,S,ON
GAS CONSTR. MAINT, & SERVICES
DATE
SKETCH
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/22/08
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt: 19391
Reference Subtotal
556 $170.00
Check#: 15083
Total Paid: $170.00
Name:
National, Grid - Gas Constr. Cept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 556
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAI/~ old T6¥1tl ~'lef[
Re£#T100876611
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 8~ 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) 885Wickham Ave. Mattituck
Address
Owner of Premises Address
3) 1-4'x4' hellhole on the W/s of Wickham Ave. approx. 210' w/o Middle Rd. to install a Ka?,
service
4) tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Builder's License No.
Electrician's License No. [ 'w' ]'~l
Plumber's License No. ~ l~
Other Trade's License No.
5-15-08
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 thc Town Clerk
6) Tax Map: Section ,Block
7) Starting Date: Completion Date:
8) Work Schedule:
, Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Covcra~c (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
Al. I /Service Connections excavations ~ $20.00 =
$150.00
$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
Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional If. ~ .30
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
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 ~-~- ~oZ
SUP/.~,RI~ENDENT OF HIGHWAYS
Peter W. Harris
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 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town CIerk
INSPECTOR'S RECORD
Inspection Date
1st
3~
4th
Findings(usecode)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - 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 forfinalsettlementofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
NO.
W.O./PA
NO.
BY