HomeMy WebLinkAbout645 Westphalia RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/22/08
* * * RECEIPT * * *
Receipt~: 19386
Transaction(s):
1 1
Permits
Reference Subtotal
553 $170.00
Check#: 15086
Total Paid: $170.00
Name:
National, Grid - Gas Constr, Cept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 553
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
ReC#T100878302 t
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 Address
2) 645 Westphalia Road Mattituck Owner of Premises Address
3) S/s Westphalia Rd. approx. 240' e/o Middle Rd, to install a gas service
4) tidal wetlands? *Yes
Builder's License No. ~///~
tAt/F7
Electrician's License No. ~/
No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Trade's License No. __
5-15-08
Date
5)
a) Attachp~~tp~ansh~wing~~cati~n~fpr~p~sedexcavati~nandrelati~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 Cleric
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 Coverage (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d)
13) Security:
a)
h)
Coverage required extended to the Town:
Bodily injury and properly 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. I /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 l.f. = $10.00 -
l.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 I.f. =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.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.
SUPERINTENDENT OF HIGHWAYS
Received by the Town Clerk ~"-' o2//~ d~ oc/
Date
Permit Issued ~'"' o~t~. ~ ~:'~"~ Permit No.
Date
Note: Permit expires one (1) year from Date of Issuance. No work to stan 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 Cle~
INSPECTOR'S RECORD
Inspection Date
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- Inspector holding forfinalsettlemcntofexcavation
RFR - Ready to Repair
D-39 Page 3 of 3
PERMIT
NO,
LOCATION
REASON FOR
OPENING
KEYSPAN
REQUESTFORSTREETOPENINGPERMIT
COUNTY ~-] SUFFOLK
MIS
W.OJPA
NO.
REQU,-a J
BY
APPROVED
IFOREMAN
DEPARTMENT
GAS CONSTR. MAINT.& SERVICE8
SKETCH
DATE OF
IDIVISION
IDATE
,I
TOTAL P. 02
N