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Home My WebLink About6900 Wickham Ave , < Perinit No. /9 If ~IW t$ QJ7,00 IOV 2 j 1999 APPLICATION /PERMIT . . Fil,e No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic 'Lane Peconic, New York 11958 (516) 765'-3140 Po_t2>c~ /7e:. A .... FOR HIGHWAY EXCAVATION AND REPAIR .;.;'i 3 (., -:;:'<;3 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) GRot) k\~,,-, U 10\0-' 6-AJ Name of Pipplicant l--(l.f?- E (YII4,..... 57- PA-1cL:J(..<!. r-y Address / 2) Name of Owner of Premises Address (S,..e I"r 'TMc.k-..!l ,Jt'SCv-~ /1,,- ) Hamlet, Cross Street) 3)~900 W\ c. 'cl-tA--- Are - vY'ATn,,-,c Ie'- Work Description and Location (Street Number, (a) Is construction lo~ated within 75 feet of tidal wetlands? *Yes_No yO *If yes, other-Iown permits may be required. 4) Builder's License No, Plumber's License No. Electrician's License No. Other Trade's License No. ~Ll IJ,*'"-- Signature of Ap t /1-ICf-'11 Date 5) a) Attach plot plan showing locatioll of proposed/excavation and relationship to adjoining premises or public streets or areas, and giving a detailed descrip- tion 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) 7l Tax Map: Section Block , Lot 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: \ 0-39 Page 1 of 3 . . 12) Insurance Coverage: (Attach copy) Insurance Company: Policy II State whether policy ment: d) Coverage required extended to the Town: Bodily injury and property damage: $300.000/$500.000 Bodily Injury. and $50.000 property damage. a) b) \ c) of certification on file with the Highway Depart- 13) Security: a) Surety Bond total amount of $ b) Maintenance Bond provided: or Certified Check provided in the 2 years or 3 years 14) Fees for applications and permits: AI. 1 IService Connections ~ A2. IAdditional Excavations same service @ $10.00 = $ ~ Basic Application Fee........ $25. 00"-- excavations @ $20.00 = $ j: {).- ~qi1 1ff B. Excavations 18" in depth or less: 0-100 I. f. = $10. 00 I. f. @ $0. 10 - $ Additional C. Excavations-l'8" in depth to 5' in depth: 0-100 I. f. =- $30. 00 J. ~4o . I. f. @ $0. 30 = $ r: 51. 00 Additional D. Excavations 5' in depth and over: 0-100 I.f. = $50.00 I.f. @ $0.50 = $ 30.- Additional E. Utility Repair Excavations @$10.00 = $ No. Repairs same service @ $5.00 = $ Additional _.---' F. Notice to public utilities proof must be provided and attached to this application prior to issuance of permit. * * * Authorization is hereby granted to the issue a Highway Excavation Permit to: in accordance with .this application. Town Clerk of the Town of Southold to 'Bt=OOIn. -Iv U.vro v ('_~ s SUPERINTENDENT OF HIGHWAYS TOWN 0 OUTHOLD. NEW YORK f (- ,?-:? -9 9- Date Received by the Town Clerk /1- il.3' y?, Date Permit Issued,' /1- 02.-)- Y7 Date Permit No. /9 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. 0-39 Page 2 of 3 . . Copy Distribution: \ Highway Department Inspector Applicant Town Clerk INS P E C TOR I ,S RECORD Inspection Date Findings (use code) Applicant Notified 1st 2nd 3rd 4th (To Permit Clerk) REMARKS CODE I B - Improper barricades IL - Improper -lights\ ST - Sunken trench Or excavation UTM - Unable to measure (due to backfilling) BUC - Building under Construction W1P - 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 Request for 5()~T74(;(";) REQUEST FOR PERMIT FEE' $ Date /I /r. if ..Permit required to open! A cj 'Xv 'x. 3' 4Et{ J/Pc~ ~ 77-Ir ~/s ~/ N''c~~ /AI€.. . d 71f<i. i..1TUSL'e-77...... ,J tvt#y'S Ih/L) fA41. /I 3'bEd -{~ I;.IfJ, r'tJ trI '[ &iUt 5'5 ..t!-,U.A 10.( 40' M<.. -tJ ( ,.j Is c f w ,'CI<t~ /4VL);u. ;JT; ,j(.,' -;; b41SS &'i.4 dU- 71ft: sls b0dfrwn1 tk~ -i- --o!z,.; I7c#l"/1':~ .f.-ASt -"'- /Hi slS cl W1,'CKlhffl4. /f/L ,f/ 77/;: ~.sS ~.4 -Isl- ,)140' t3:,Jb(')~ ~/,;ee)C 7~o' .E-/o /td/(( 4 ,:J p#ftYT//<A.'NC.. TD /300 Type of Road Work Request # J-4365.- 0 Charge account # * 0 0 isbursement to be made out of petty cash Return Permit To: Business Department Cf{~L o O.N. 0 Cent. 0 W.S. g E.S. Permit Requested By: Gas Service for o To be billed 0 No fee o Underground Lines Department o Qper. Plan. & Cont. Center FC_1145.6-SS . KEYSPAN ENERGY CORP. dbo BROOKLYN UNION GAS CO. Main & Svc AREA# 2.4 REF#!WO# 24.3t5 -13.0' ^"PucmT utlss:R.ifS PHOI'E 'S/t. Z1lb -S'1%.f CHID. /1)1- -'1 StlMeE ADO. h"J 0 0 . /L. VIllAGE I11lrrn CUSTOMer< CONTACT AOO'/PlIONE , 0 . FT MAIN $ NO c,t/t4L4-L TIoX OIST eFT SERVICES $ N4JCA 'M.GL PERMIT HEa "DO RELOCATION $ TYPE PEH""~W'" -I- c"'v,~. REACTIVATION $ SERVICE HED' BY ASAP SURVEY BYXevin. Schutz DATE II .SALES TAX $ CONNECTED LOAD FIELD CON DillON DATA CHARGE TO. APPLICANT $ '() "<AnHC q 0 ~~"oJcTlON SURVEY PLANS 0 FOUNDATION ONLY 0 FRAMED 0 COMPLErE IX1 WATERG ''rE OF SEWAGE CESSPOOlS 0 SEPTIC T^NK~ 0 - r~~tAL DO RANGE WPE HESlOENcw.] fXlSlING WATER MAIN INSTAULED YES ~:J NO _ DRYER Dr COMMERCIAL 00 NEW .., WATER SERVICE INSTAlLEO YES ,~ NO PREMISES : APT ICONDO 0 REBUI1.T 0 WELL SERVICE INSTALLED YES" NO INSTALL MAIN 0 CUT8ACK 0 ANODE ON RISeR 0 CONSTRUCllON REPORT DATA CFH eF" em CFH INSULAl't AT S"MeE 0 TOTAL '?'3 0 23300 <I-b WI erH OTllm CONsmuCllON SCHEDULED ~.EK or ~"NU COMPlETE FORMAN B.I. , SALE.'; sup I P.A. , AIR lEST OVERAIJ. FOOTAGE S€"VlC[ ORDER APPROVED IN SERVICE ORDER '"'All': ,. 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'13 File No. 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, ordinimces 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) t3ROll kl~.-> U ~\O""" 6-I'rJ Name of P\pplicant L-{t..ftf-. E (YII4,...... ST- (J.4-lc.L.oJ<...,,- r- Y Address / 2) Name of Owner of Premises Address ( s .,. ~ I"r ITvk ~ -..-0 d<; CI-'-o( /I d~ ) Hamlet, Cross Street) 3)~OO W\ C. 'c.l"A-- ~ - ;lY'A\T\\'.-.c lC- Work Description and Location (Street Number, (a) Is construction lo~ated within 75 feet of tidal wetlands? *Yes *If yes, other-fown permits may be required. No -.,0 4) Builder's License No. Plumber's License No. Electrician's License No. Other Trade's License No. ,.'" ~OO~t ~tl IJ~," Signature of Ap t 1/-/9-91 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 descrip- tion 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. Tax Map: Section , Block , Lot 6) 7) Starting Date: Completion Date 8) Work Schedule: \ Excavation. . . . . . . . . . . . . . . . . . . .. .. '\: . . . . . . . . . . . . . . . . . Phase Completion Date Facility Installation................................. Backfill & Compaction.............................. Pavement Replacement........ .'...................... 9) Under which authority is the application made: 10) Estimated Cost of Proposed Work: $ 11) Remarks: \ D-39 Page 1 of 3 12) . Insurance Coverage: (Attach a) Insurance Company: b) Policy # c) State whether policy ment: d) Coverage required extended to the Town: Bodily injury and property damage: $300.000/$500.000 Bodily Injury. and $50.000 property damage. copy) . \ of certification on. file with the Highway Depart- 13) Security: a) Surety Bond total amount of $ b) Maintenance Bond provided{ or Certified Check provided in the 2 years or 3 years 14) Fees for applications and permits: Basic A 1. I /Service Connections. excavations No. A2. /Additional Excavations same service @ $10.00 = $ Application Fee........ $25. 00"'- , @ $20.00 =-$ ~{).- ~qil 1pf No. B. Excavations 18" in depth or less: 0-100 I.f. = $10.00 I.f. @ $0.10 -_$ Additional C. Excavations.,.l'8" in depth to 5' in depth: 0-100 I. f. =. $30.00 ~ ~4D . I. f. @ $0. 30 =. $ ~ 52. . 00 Additional D. Excavations 5' in depth and over: 0-100 I.f. = $50.00 I. f. @ $0.50 = $ 30.- Additional E. Utility Repair. Excavations @$10.00 = $ No. Repairs same service @ $5.00 = $ Additional / / -- F. Notice to public utilities proof must be provided this application prior to issuance of permit. and attached to / / * * *: Authorization is hereby granted to the lown Clerk of the Town of Southold to issue a Highway Excavation Permit to: in accordance with .this application. SUPERINTENDENT OF HIGHWAYS TOWN OF OUTHOLD. NEW YORK 1(-,73 97' Date Received by the Town Clerk Date Permit Issued\' Permit No. Date 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 INS P E C TOR I \S RECORD , \ , , '> I nspection Date Findings '(use code) Applicant Notified 1st 2nd 3rd 4th (To Permit Clerk) ...-..." REMARKS / /' CODE IB - Improper barricades IL - Improper -lightS'. ST - Sunken trench"o~ excavation UTM - Unable to measure (due to backfilling) BUC - Building under Constructi.on 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 . . REQUEST FOR PERMIT Request for 5o......:n~~,(~.";) Permit FEE' $ Date /I /If'. Permit required to open! II <I 'XV 'x.?:. ' 4lt{ ffi,CE rvt. 7Jlr #ft."f' N/'cK'~ ~ d 71I:"i.. f,.JTuSre.77.,.,...,f fV{#y~ Ih/L} 1A41. /1 3'bEd -;1l,;,J:w ;;'/l-JI ( jJ -nI r 6--# 5'5' ;l!-li-t:A A j if 0' tnL. (1/ f. .J Is c r IN "CI<t~ /lVL; ,<<,"J.r,' cJl,,';; 641ss 4-t~4 ~ 7111: sjs MU;!wrl1 /hIL -i- -r/h,J /7qJ<-";t;~ ..f-Mr ~ Illi s(s DI w;el(/.h4-m. ,0/L ,fJ 771r GlA-sS ~Il -/-,,1- .).140' E=,Jbf'iJG- ,I1J?"/<~)t 7:Zo I .c/o M;t( /./ ,/1 If/IfrtTI/:lt!1C. Permit Requested By: c t<...i.l L o O.N. 0 Cent. 0 W.S. g E.S. TD /300 Type of Road Work Request # cJ.43('S ~ 0 Charge account # it 0 Disbursement to be made out of petty cash Return Permit To: Business Department Gas Service for o To be billed 0 No fee o Underground Lines Department DOper. Plan. & Cont. Center FC-1145.6-SS