HomeMy WebLinkAbout500 Westphalia Ave
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 07/22/03
Receipt#:
1721
Permits
Check#: 1721
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
--11)
;y
4
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
InternallD: 79720
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconlc Lane
Peconic, New York 11958
(631) 765-3140
APPLICA nON/PERMIT FOR HIGHWAY EXCA VA nON AND REPAIR
Ref.#T100299439
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 orthe Code or the Town of South old, 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 or the
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 500 Westnhalia Avenue. Mattituek
Name of Owner of Premises
Address
3) Westnhalia Avenue - bellhole sls paved area annrox. 500' elo CR #48 (Middle Rd). Mattituek. to install a
new l!as service to #500
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tra 's License No.
Signatur of A
07-11-03
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 Comoletion Date
Excavation...................... ...................................................
Facility Installation........................................................... ....
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
T1 00299439
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
Ii) 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 $50,000 property damage.
13) Securitv:
a)
Ii)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoohcatlOns and Dcrmlts Basic Aoolication Fee........,..... ,.. $25.00
A 1. ~/Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. ~I Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 J.f. ~ $10.00
I.f. @ $O.IO~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00 ~
_1.f. @ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 J.f. ~ $50.00
J.f. @$0.50~$
Additional
E.
Utility Repair Excavations @ $1 0.00 ~ $
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 $45.00
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 7/,5l. ",10 . ~
7 /Ol~/D.!J
Date
Permit No.
OJ.. 76
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 of3
JUL.-Oi'03(MONI08:45
BU GAS DESIGN PATCH TEL:516 i585136
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REQUEST FOR STREET OPENING PERMIT
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~~QUESTED
BY
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