HomeMy WebLinkAbout5635 Westphalia Rd ` Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 125616
Date: 02/07/12
Reference Subtotal
Transaction(s):
1 1 Excavation Permits
746 $170.00
Check#: 22144 Total Paid: $170.00
Name: National, Grid -Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Internal ID:746
Clerk ID: LINDAC
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Permit No. TOWN OF SOUTHOLD 4
HIGHWAY DEPARTMENT
File No. Peconic Lane
Peconic,New York 11958 `"' „
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR S_ °� •s
W.O.#T101320124
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) 5635 Westphalia Rd. Mattituck Owner of Premises Address
3) 1-4'x4' bellhole on the S/s of Westphalia Rd.,60' w/o Illinois Ave.,to install a gas service.
4)
5)
6)
7) tidal wetlands? *Yes No_X
*If yes,other Town permits may be required.
Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
A44-- JU4
Signature of Applicant
01-25-I2
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 Town Clerk.
6) Tax Map: Section ,Block ,Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase Completion Date
Excavation.........................................................................
FacilityInstallation...............................................................
Backfill&Compaction.........................................................
Pavement Repla:ement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
4l) Remarks:
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$50,000 property damage.
13) Securi :
a) Surety Bond or Certified Check provided in the total amount
of$
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. _1 /Service Connections excavations @$20.00= $20.00
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
C. Excavations 18"in depth to 5' in depth:
0-100 l.f._
Additional If @30=
D. Excavations 5' in depth and over:
0-100 Lf._$50.00
l.f. @$0.50=$
Additional
E. Utility Repair Excavations @$10.00=$
No.
Repairs same service @$5.00=$
Additional
F. Notice to public utilities proof ml_,st 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.
SUPE NDENT OF HIGHWAYS
TO OF S UTHOLD,NE ORK
Peter W.Harris
Received by the Town Clerk
l—,Z -7 /L Date
Date '
Permit Issued ?-7-1 Z— 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 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date Findings(use code) Applicant Notified
I St
2nd
3 rd
4th
(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 final settlement of excavation
RFR— Ready to Repair
D-39 Page 3 of 3
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