HomeMy WebLinkAbout4330 Westphalia RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/17/09
* * * RECEIPT * * *
Receipt#: 41684
Transaction(s):
1 1
Permits
Reference Subtotal
605 $206.90
Check#:16572
Total Paid: $206.90
Name:
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 605
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T1009732~4
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) KEYSPAN ENERGY- GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD.- HICKSVILLE, NY 11801
Name of Applicant Address
2) 4330 Westphalia Rd.
Mattituck
Owner of Premises Address
2-4'x4' bellholes and a 124' trench in the S/s grass areal approximately 40' e/o Oakleaf La.~ to
install a gas main and gas service to house #4330.
4)
4) Builder's License No.
Electrician's License No.
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.
s)
No X
Plumber's LicenseNo.
Other Trade's License No.
01/'21/09
Date
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 ora Highway Excavation Permit
by the 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:
D-39
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy ofcartification 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 applications and permits: Basic Application Fee
Al. /Service Connections excavations ~ $20.00 =
100' trench fee
A2. /Additional Excavations same service ~ $10.00 ~
No.
$150.00
+ 20.00 hellhole +30.00 for
And .30 ea. foot from 101'
$99.00)
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
l.f. ~ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. -
Additional lf~ .30 = oftranch 124'
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 = $
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $206.90
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 <:~ --,/,n/~ 19 ~ Date
Permit Issued ar9 - / 7- O ~' Permit No.
SUP, Fa-RINTENDENT OF HIGHWAYS
TO,~VN bF SOUTHO, LI~, NEW YORK
Peter W. Harris
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 of 3
Cor~v Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
2,,~
Findings (use code)
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
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REQUEST FOR STREET O~ENINQ II'ERNIT
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