HomeMy WebLinkAbout4735 Westphalia Ave ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 M~in Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
F A X
To~
From:
Re:
Date:
Pages:
Janet, Keyspan
516/545-4474
Lynda M Bohn
Highway Excavation Permit # 345
October 8, 2004
4 including cover
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.#T100417470
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 agr~.a to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections of the
job site~
!) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 4735 Westphalia Avenue, Mattituck
Name of Owner of Premises
Address
3)
Westphalia Avenue - 1370' trench in s's grass area e/o Cox-Neck Road
Howard Avenue - 35' trench e/s grass area n/o Westphalia Avenue
Illinois Avenue - 35' trench in e/s grass area n/o Westphalia Avenue
Cox Neck Road - 1651' trench in w/s grass area n/o C.R. #48 134iddle Road)
Sound Avenue - 765' trench in s/s grass area s/e of C.R. g48 (Middle Road)
Installation of gas main and gas service to 4735 Westphalia Avenue~ Mattituck
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction Iocal~d within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other Tr~ License No.
//] VSignature of A~plica~t '
~/ 9-01-04
Da~
a) A~ach plot plan showing lo~tion of proposed excavation and relationship to adjoining premises or
public struts or areas, and giving a detall~ dese~ption 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 .........................................................
Comnletion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
T100417470
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
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 = $20.00
$ 25.00
A2. /Additional Excavations same service @ $10.00 =
No.
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:
_1.£ @ $0.30 =
0-1001.f. = $30.00 (100' trench)
Additional 3,756' = $1,126.80
= $ 30.00
-- $1,126.80
C. Excavations 5' in depth and over:
0-1001.f. = $50.00
l.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 = $1~201.80
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.
SUPE~ENT OF HIGHWAYS
Peter W. H~
Receiv~ by ~e To~ Cl~k /
Pemitlssued /O/,/O~ Pe=itSo. ~ qff
P~it must be available for inspirit.
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/07/04
Transaction(s):
1 Permits
Receipt:
3756
Subtotal
$1,201.80
Check#:3756
Total Paid: $1,201.80
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Intemal ID: 101106
KEYSPRN GRS CONSTR
6~1 ?58 5136 P.02
4,.
KEYSP~N G~S CONSTR
KEYSPAN GAS CONSTR
631 758 5136
P. 04
KEYSPAN GAS CONSTR
~31 ?58 51~6
P. 05
N
~UG-27-2004 10:29 KEYSP~N G~S CONSTR 6~1 758 51~6 P.06
KEYSPAN GAS CONSTR
631 ?58 5136
P. 07
N
P. 08
56£
N
~UG-~?-200~ 10:2~ KEYSP~N G~S CONSTR 6~1 ?58 ~1~6 P.O~
AUG-~?-~00~ 10:~0
KEYSPAN GAS CONSTR
651 758 5136
P, 10
AUG-~?-2004
10:30
KEYSPAN GAS CONSTR
631 ?58 5136 P.11
TOTAL P.11
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
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 Constmction
WlP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS - Inspector holding for final settlemant of excavation
RFR- Ready to Repair
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