HomeMy WebLinkAbout165 Westphalia RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 04/15/04
Transaction(s):
Permits
Receipt:
2989
Subtotal
$45.00
Check#: 2989
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 92332
Permit No. 1~
File No. /~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGIC~AY EXCAVATION AND REPAIR
Ref.#T100376469
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Soutbeld for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe Code of the Town of Soutbeld, 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 oftbe
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY ! 1801
Name of Applicant Address
2) 165 Westphalia Road~ Mattituck
Name of Owner of Premises
3)
Address
Westphalia Road - bellhole s/s hayed area anurox. 116' e/o Deer Drive. Mattituck. to install a ess main
andgas service to #165 Westnhalia Road
Work D~seription 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.
Electrician's License No.
s)
Plumber's License No.
Other ~e's License No. ·
Signature/of A~pli~aat
°4-~tat4e4
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
7) Starting Date:
8) Work Schedule:
, Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
D-39
Pagelof3
T100376469
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
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoolications and permits: Basic Application Fee ................. $25.00
Al. _1 /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. __/Additional Excavations same service ~ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 I.£. = $10.00
l.fi ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 =
__ l.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.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 ~1.5.00
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.
Received by the Town Clerk
Date
Permit Issued '9///~7~ c.~
Permit No. X~/~
SUPE~DENT OF HIGHWAYS
TOWS'OF S XHOkD,
'
f f ~te
Not__e: 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 Page2of3
P'ERMIT
LOCATION
REAEON FOR
OPENING
WoO.IPA
NO.
REQUEETED
6Y
APPROVED
K(~T~PAN GAS CONSTR
KEYSPAN
FIEGUEST FOR STREET OPENING PERMIT
n-1 STATE E'-] "AssAu SU;FOL~:
~UNTY ~
FOREMAN DATE OF
, O~NING ·
DEPARTMENT ] DIVISION
GAS GONER, MAINT, & 5ERVfGE8
JDATE
P. 02
I
I
I
I
TOTAL P.02