HomeMy WebLinkAbout4055 Westphalia Rd
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 117.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #154
1 - Permits on 01/23/2002.
Thank you.
Permit No.
Is-if
IS^,
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
APPLICA TIONIPERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe Code of 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 of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Ms. Barbara Raacke - 4055 Westlnhalia Rd. - Mattitnck
Name of Owner of Premises
(#T100121221)
Address
3) ODeD & restore - Westohalia Rd. -.bell hole & 240' trench in the s/s l!rass area e/o Oak Leaf La.
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.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
ture Appr
01-14-02
Date
S) 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
Tl00121221
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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic Aoolication Fee.............. ... $25.00
AI. ~/Service Connections excavations@$20.00=$ 20.00
No.
A2. _/Additional Excavations same service@SI0.00=$
No.
B. Excavations 18" in depth or less:
0-100 1.1 ~ $10.00
Lf. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth: 240'
0-100 I.f. = $30.00
140 1.1 @ $0.30 ~ $ 42.00
Additional
D. Excavations 5' in depth and over:
0-100 1.1 ~ $50.00
I.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 $117.00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application,
SUPER1NTENDENT OF HIGHWAYS
TO'G:THOLD, NEW YORK
6l~R~
Peter W. arris
Received by the Town Clerk
1- <<J-tJ ~
61- Ol.;l -oa
Date
Permit Issued
/-t1-3-0;J".,
Date
Permit No.
/.5"1.1
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pennit must be available for inspection.
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