HomeMy WebLinkAbout645 Westphalia Rd (2) ti
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/07/12 Receipt#: 143683
Transaction(s): Reference Subtotal
1 1 Excavation Permits 803 $170.00
Check#: 23666 Total Paid: $170.00
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 803
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Permit No. TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. U Peconic Lane
Peconic,New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.T101419065
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 Rd. Owner of Premises Address
3) RECEIVED
4) open a-4'x4'3 bellhole on the S/s of Westphalia 175' e/o County Rd.,48 to repair a gas
leak.
5)
6)
7)
8) tidal wetlands? *Yes No X
*If yes,other Town permits may be required. Southold Town Clerk
Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
Signature of Applicant
11-30-12
Date
5) 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 TOwli C',1.k.
6) Tax Map: Section Block Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase Completion Date
Excavation .........................................................................
Facility Installation...............................................................
Backfill&Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: S
11) Remarks:
12) Insurance Coverage(Attach Copy)
5
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: S300,000/$500,000 Bodily Injury,and 550,000 property damage.
13) Security:
a) Surety Bond or Certified Check provided in the total amount
of S
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. —1iService Connections excavations ra; 520.00= 520.00
A2. /Additional Excavations same service(it, S 10.00=
No.
B. Excavations 18"in depth or less:
0-100 I.f.=S 10.00-
I.f. a 50.10=
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f._
Additional If. a .30=
D. Fxcavations 5' in depth and over:
0-100 I-f._$50.00
Lf Cc�;S0.50=$
Additional
E. Utility Repair Excavations S 10.00=$
No.
Repairs same service(d 55.00=5
Additional
F. 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 accordant„with this application.
SUPERINTENDENT OF IGH WAYS
TO SOUTHOLD NEW YORK
Peter W. arriis �
Received by the Town Clerk ✓✓✓✓ Date
Date
Permit Issued Permit No.
Note: Permit expires one(1)year trom Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit nwst be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
IN'S PECTO RIS RECORD
Inspection Date Findings(use code) Applicant Notified
I"
3";
(To Permit Clerk)
REMARKS
CODE
[B— 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 final settlement of excavation
RFR— Ready to Repair
D-39
Page 3 of 3
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REQUEST FOR STREET OPENING PERMIT
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NASSAU SUFFOLK
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PERMIT
NO. NO. JOB ��/ � � DATE
LOCATION
REASON FOR
OPENING %FP�i/c
W.O./PA FOREMAN PDATEOF
NO. NG
REQUESTED DEPARTMENT DIBY J'f1'f IL GAS CONSTR. MAINT. & SERVICES /z�
APPROVED DATE
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