HomeMy WebLinkAbout5825 Westphalia RdTown Of Southo[d
P.O Box 1179
Southold, NY 11971
Date: 08/11/05
* * * RECEIPT * * *
Receipt#: 5225
Transaction(s):
1 1
Permits
Reference Subtotal
399 $170.00
Check#: 5225
Total Paid: $170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 399
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
RECEIVED
Ref.#T100516040
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) 5825 Westphalia Rd., Matituck
Name of Owner of Premises Address
3) Westphalia Road - bellhole s/s of Westphalia Road~ 200' e/o Cox Neck Road~ to install a gas
service to #5825
4) Work D~scription and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trades License No.
, Si nre0 30.05 f ppl'anf
Date
5) a) At(ach 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
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 Page I of 3
T100516040
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)
Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 = $20.00
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
I.£ ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi =
Additional If. ~ .30 =
D. Excavations 5' in depth and over:
0-1001.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 oftbe Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this applicahon.
Received by the Town Clerk
Permit Issued
SU~'"~F~DENT OF HIGH~VAYS
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 Page2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1~t
2~
3~a
nth
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 - Improper backfill (too high) (not sufficient)
HFS- Inspector holding for finalsettlement of excavation
RFR- Ready to Repair
D-39 Page 3 of 3
P~T APPLICATION SKETCH
DATE:
LOCATION:
TOW~:
WORK ORDER:
6/30/2(305 11:06:12 AM
5~25 V~STPHALIA AVE
MATI]TUCK
Ti00516040
VILLAGE
CROSS SrP. EET: COX NECK RD
~URFACE:
M.~lara Road
I~ NO.
5~25
//~ 200'
Bell Hole
x
o
~ESTPHAII A AVE