HomeMy WebLinkAboutKimogener Point
File No.
02D
020
.
.
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'-3140
~ t.(5'r~ P D, /2>0r- I 7 e:,
IOV 2 3 1~PLlCATlON/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
.
MCIffttJ
d- '1'1:)'-1- 93
..ll'-
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)
AJ U. IV I
licant
;--.' frM - '-IV? C rrlril,.J S-.- f?A.. Ic..t...o L.<=-
Address
2)
Name of Owner of Premises I.{,....... 0 NJ~ II! {l,j ,~,- <R.P. Address
'-f' .,. Y I IS!"/I ~~ [),\j (k '0- 1<). ~1?t<'fC ns I 5/., .jA<t:So~ /'Iv-<-
Work Description and Location (Street Number, Harrfiet, Cross Street)
3)
(a) Is construction los::ated within 75 feet of tidal wetlands? *Yes_No
*If yes, other-'Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
/~ I~L~
Signature of JA.~licant
/ /- I '1' 97
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.
6)
7)
Tax Map: Section
, Block
, Lot
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: $
11)
Remarks:
\
D-39
Page 1 of 3
.
.
,;JYL/:J''1 '7'3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
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
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
3 years
14)
Fees for applications and permits:
A 1. ---L-/Service Connections
No.
A2. IAdditional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ dO ("V
No.
B. Excavations 18" in depth or less:
0-100 I. f. = $10. 00
I. f. @ $0.10 - $
Additional
C. Excavations.-l8" in depth to 5' in depth:
0-100 I.f. = $30.00
.I.f. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 = $
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
i31200KL 'fAJ (.hurod GPi.s
SUPERINTENDENT OF HIGHWAYS
T~OLD'~
, Raymont ~acobs
1(- 73 -er9
Date
Received by the Town Clerk
//-023-77
Date
Permit Issued, //-,2-1-17'
Date
Permi t No. r:Q.i:)
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
.
.
cJ LjySY 7-.S
'Copy Distribution:
\
Highway Department
Inspector
Applicant
Town Clerk
INS P E C TOR ',S
RECORD
I nspection 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
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
(-'40 DII -~'3"3cDo3 1/16 ~.o-
RESIDENTIAL GAS REQUEST FORM
. KeySpan Ga~ Corp.d/b/a/Broo. Union
BU
CHECK USAGE BTU INPUTIHR THERMS/YR S uare Foota e Heated S ace
Large Meter :..Type Size
EXISTING LOAD Account # L. LOS 7..7..1 0 ~
NEW SPACE HEATING ./ [00000 I ",ot) Grid # 0\ 1..( <. '3Z"6
NEW WATER HEATING Regulator Size
NEW COOKING In-House Pressure
NEW DRYING New Rate Code
NEW PROCESSING Degree Days
TOTALS Dom. Factor
IMPORTANT NOTICE TO CUSTOMERS REQUIRING INSTALLATION OF A NEW BROOKLUYN UNION GAS PIPE
By Signing below, I am certifying that I am the owner or have the permission of the owner to authorize the instanation of Brooklyn facilities at this property. I
further understand that ifBrooklyn Union installs a new gas pipe at my reques~ and I do not use the service that I must pay Brooklyn Union for the entire cost of the
insl:1llation in accordance with KeySpan Gas Corp's dIbIa Brooklyn Union Gas Tarin: Leaf No. 12A. Section 2B, 4.4 as approved by the Public Service
\ Commission. I also understand that Brooklyn Union is not responsible for repaving or landscaping on private property. I have read and agree to the General
Requirements and conditions of the reverse side. .. . I
I
\ Customer Name: (Print)
CustomcrlBU Agreement Date } J ~ I 1 - q p
"
DYes
,
\ Is Gas Capacity Request Required?......
\ Is Rcgional EnglEngineeringReq? ......
Arc cxcess Attachment Charges Required?
WORK REQUIREMENTS
I No Work Required........ 0 New Gas Main w/Service ..... 0
: Upgrade Meter... ...... ...B Serv~cc Upgrad~.................. 0
\ }:ew }.leter...... ...........fl ServIce RelocatIon............... 0
\ RiserlHeaderWork........f?r Me.te:Reloc.ation..... ...........0
New Gas Selvice Laterall;il.; EXlSung BUIlding... YES oNO
,
SITE INFORMATION
DYes
DYes
o Cesspool
oOil tank
o Sprinkler
o
Macadam oNone
o Concrete oTree
o Dirt/Sod 0 Steep Incline
o DUG Etecir;c
o Customer to remove/cut back bush
o Customer to install protection posts
o Customer to install pad t
New Service Diam ~
Meter 0 Inside
Existing Main Diam ~
~n~~~
IV1tI .s~l..
pres.B:f-
o ..Remote
Pres ~-f'
Pres_
New Main
Diam
Length _
eter Order #
WorkOrder# 0
One Call Case #
GAS USE
1300
s=-->~l.\l
$,
-f..
~tt cl,;::s o.~ S-I-
CUSTOMER A UTHOR!ZA TION
OF METER LOCATION
5!?
~
()
!?
",1/
-N-
/1'"
Street
\3. 0\ 'N'H) Y"\ ~ e ~
COMMENTS
t
Q6\nt
u
~ ~
LefT
d..fl d. )-10 tJSP () n
/05 . .
HS-e AClt...:5 WAifc.. wdJ.... fore!-'
hQS 0 sjf' IilJt~;'nJfd"-'t /"Ies!
WR.oY\~ ~ilCl () Yl Lot G5
.s v PT : () 0 c:l 00 l.
.a;;l.,
Date
Customer Sig:
O.
_/ C.......;.....
n(~)..
BIU Rep Sig:
~~
14.
'-
.1/3 I FT MAIN $"'[J"tI~~u-
4-0 FT SERVICES $ tJ CHiI~
RELOCATION i
REACTIVATION $
SURVEY BY Kevin Schutz DATE II I SALES TAX $
rlELD CONDITlON DATA CHARGE TO APPLICANT $
STArr OF 0 T N ON Y 0 FRAMED rl COMPLETE r"'. 'I
c0~siRlIC~ON SURVEY PLANS FOUNDA 10 L 'L_. '^
1Y!,\~ OF SE",lJAGE CESSN)QLS 0 SEPTIC TANKS 0 ,~i~l~I~"L [~:.
lYPE RES1DENCw.. LJ EXISTING WATER MAIN lNSTALU:O
or COMMERCI^L 00 NEW '. _ W^TER sERVlCE INSTN..LED
PREMlSlS , IIPT/CONOO 0 REBUILT 0 WELL SERVlCE INSTAl.LEO
INSTALL
MAIN 0 CUTBACK 0 ANODE ON RISER 0
CONSTRucnON REPORT
TAX OIST
PERMIT REO NO 0
T'rl'E PERMIT J'rJ1Ti 1- -,o"J,J
SEIMCE REO' BY ASAP
CONNECTED LOAD DATA
HlAlINC /3 -00 0 C'H
WATER- CH.l
t~' :nN~
RANGE CFl1
YCS D
YES .~
YES ~
NO f7'iI
NO gJ
NO ']
ORYfR
OTHER
INSULATE AT
Ol?1!J
23300/0
CFH
CFH
CFH
SEfMCE 0
TOTAL.
8.1, *
SALES
SUP I
PA'
CONSTRUCTION SCHEDULED WEEK OF
STNU COMPLETt
FORMAN
AIR T[$T
seRVICE ORDER
APPROVEO BY
SERVlCE ORDER
A I
NOTIFY ONE-CALL CENTER BEFORE DIGGING 1 800 272 4480
Brooklyn Union is not responsible for repaving or restorial costs on Private Property
:rHs1A.LL j; 3. i' €)t t.j"flfJ Mb ILsj f11f1IIJ
:EJs-rAIL 5 ~ (t' fll M'b IL5II/ALv'fS"
:LrJruLL 40'" f cf-")lf? 1117) II.s:r S:vU
-7'L6It.H 1I1A'/'r/S /I'l ~sr ~s
f'Uiss;Lf. DL },tl.,'U fl..;A-J::. t!..f..D5S/J6-S (~Ab5 &=CbI7t...Y r9tvn)
t!ailiJhlt7llJrJ L!iftl;;, d..rr JJ/SC.1E'J:arl' -tf~ U./UbJA.Y CbSS/',J&-s"
n. tJ... 6-. --rD DuiO,tj"WcLMll ;lLAj}E~ ,t:'oL 7 M '~JtldiL/;!ir(es-t4-:A-O&
h./J.&, --r; IN'S7A-LLI-/33f1 17sihL fd,UtAlO;( h~ ti4c;1ib:/~@d-#s
;J,ST"ML <I ~sI' alL,all ;t)J
IP.D 1iuIVf. Ib.rJ:r
OVEIW.L F'OOT;.GE:
~.\ ft:T i.
r "
t2LLr~vUf.Il.S ~Jf~L --;;;
(!" s-;;' vtII LIS eo J/.lA-e:1O'( ID
/
\
SH~L-j I ~f c;
sa iHrA-tflih .sulL.~1lS
\
.
.
S,~,
( MA;,..) fUL. )
#'25
t. ':s7z - -
- \\
1)"\ r
...L
/1
1 "~""
1
~)lS :l?
1 I"">
S(.AlI~ j ~
.-- ~
1
c
1 r::::...
4>
I
~ I
~:tt I
. \ I
Pi l "". I W.o.#2448'1-13D
. ~ t1;tli'D ff' /M-I.]-..:l+4-
srILrlL j- ~ I\J
l'"
fVI ,,4LA;>> /ho1 I
"i!.U. f1Lz,U! utI. I
I
\ I
$tc SilHI :iT 3
A fl
1/
.
5, f.~ shcr $I. d..
I
I
.
11
. .
" R
P s:"'-"'- 5H~ tJ; 3. ~
=
,
fJ; 1 -I
I
I
1
I
Pif-f I
-I
I
I.
I '.
.-...,.- . "
.-~.", .'
:..;-.
-
#'VI M..A l>Jl?v'.
~q - r
1
I
I
,
I
Iii /0 -I LV.O, ~llj4 f31-tf3o
, ' (5tJ"i) tt 1/11- /3- 4-
I I\J
S~'iJ5 <f-,JF
I
I '\ .
I
I
141 /1 -,
'.
I
\ I
\
\ I
.\
" -, .. - , '-' 1+ - I/'
-----------
.
c..
.
.s il.. _Srl2'f. -:- $:: 1-
1
RttrL -I
(!..
\'\1 ~
1 . "J?
~
I
1
t5' \
1 T"--
;:i:>
P.~13 I D~i,J-ft"6-f... ~
81
W,O, -tf244e1~ 130 ./ 1
I
t'::Ili'iJ ~ /~/- 1<1- 2-
Stlii-I 5 if I,
I
I
Pd /4 I
-I
:J+D ~
...-<' ' . I
l\r:.-'~
"" 2" /."-- PL I
...J... - I. I. '.b
.'
:1 2" '17l ,,\,s'-' J .~ ~
.. A- ,':0 .J:-lis I
::L- 1 qt.../" PiS'('. ~ULll
\
.>
I
!-J,S ~
I' "10'
2''S'1L ~ - ~,,~
MI1S;U "t. "b;L~LiU.'
~-. - - - .....
. . ~o'
.
4',Cl.' '
fl.:5l' U"....Cf../J....
JJ~ uJ. s.~ f/~ LJ!.
\J
\ ~
; "
-1:)
I U.~fb:Jt:-(fL .
15~ ~ \
-1><1- - .-
I..
R
Ih/&
L
::t
~
...
i
~
t:;
)\ I .Sc~
WI A U-A-r; 0 K.A
f!..O-A- "h
l--\e:-.~
~-
:x:... -d <!!.
J"'I .
r'\ !+ ~.
-) ...... ('.l
~~~
...... ~
6 '~
~~~
()> I ,
~,~
UJ
I;)
j~Z
/ .
, \
slliz T :#
<-
ii'
.,....
,. <-
l/\
...
,...
".~
R
, ." ,I'-
:";~
"-
..~
~
5~
\.
I e f!,t 3 b \\
. . \
\
\
'.
\"
,
I
I
I t~ ~'7
I. "
I
I
I
/111 kC. ....~,
Af'~1
I
: 'I .
t
1
'. "'
.1
(J..tI:r'i>
/l'1.~c'.4--';:'A-1-u
~
,e frtcj1
I
I
I
I 1v1~J;1rM.
I
I. .f2;t:c.f{;
S f.E S:1f'tL I :{i '7
c
~
Ie
.sH~E'f J;/. (,. eE I
<=-.
("';:,
.--
<:..-.
L/\
F
.. .+-7
-~
~
r--
~.,
~
. .....('1'
~~~
M tj <::;:::>
-\ 'l\. "\\
,9.J
, '0 ..c..
.....,'-~
\
I:l '" ~
-~~ -1
b() \ .
~.~
G
/r--- Z
\
1
,_ ~4(
J
I
I
:I
I
.l-
I
'I
I
1
I /6", L
...-n
V\
~~
tLur -/1"( Lc.
1 1),,(, I<.o.w.
~ --l><l- - - -
I
IA
:r- '
,....
!,>,
-I
L:
\'
i
.
.
d
- .
p
~ ~\
~ ~\
t~ ~
~~.
o _\ r>
'" "'- ~
L-, ('"
~ l/)
'-")
p
),
r;
V0
kf
t
:t:::::..- - -
It> ,
/~ Su
., \-.: I
vI ,\
~ e1) ~.
... I
.,
~ -1-.,,-
.... I
"- 4:>-
--I
.... ~ I
~\ ...
f', -:,
r--
.... l.-:l
<" I
f' .
~ I
l0 I
~ i;\ J
~r-
~ ~~\
,
~ L.~ ...l:l,
~r; ~ I,j.l~
~ ~ rl'~
U\ ~ ~t;..
f"\ M
~ -
lJ) ~ .....,
-\
~ I
I
I
1\1 I
LN. o. ~ z..44e1- '1 ~o I
&R.;b ~ /0/- /<1- 4 . I
~rlc21 \ ~ ~t~
S ii.$.~ullJ 1
Permit No.
e
.
.
File No.
eTOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic, New York 11958
(516) 765'-31liO
PO, 12>0'1- /7 e:,
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
c:2 yyj'l- 93
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 m1ake' necessary, inspections of the job site.
, , -
Print or Type
1)
A.J U /IJ I
Iicant
,
I-' &-M- '-IV? C /1114/,.) S..-
Address
flA- r-c.J, CJ (.. <--
2)
Name of Owner of Premises l<,,,,,, 0 tVj.. If! Po ,~t-.,e.P, Address
4 I )l. Y I 1<", /1 ~ 0.. ON (k '0-- f<). A-.p(J ~ 'I'" /7 5' I 51. .j Ai: t::S" -> /'tv<-
Work Description and Location (Street Number, Hanfi'et, Cross Street)
3)
(a)
Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other-fown permits may be required.
No
li) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
cc
(Q)~
?
/~ I~L~
Signature of i'\~licant
11-19-9'1
Date
5) a) Attach plot plan showing locatiohof proposed/el5cavation and relationship to
adjoining premises or public' stre,ets 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)
7)
Tax Map: Section
Block
, Lot
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: $
11)
Remarks:
"
D-39
Page 1 of 3
.
12) Insurance Coverage: (Attach copy)
.
;;YL/S-173
a)
b)
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.
c)
\
of certification on. file with the Highway Depart-
13)
Security:
a) Surety Bond
total amount of $
b) Maintenance Bond
or Certified Check
provided in the
provided:
\
2 years or
3 years
14) Fees for applications and permits: Basic Appl icatio~ Fee........ $25.00
A 1. -1-IService Connections. excavations @ $20.00 =, $ ;J(). c,o
No.
A2. IAdditional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth o'r less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
Additional
C. Excavations.oOt8" in depth t.o 5' in depth:
0-100 I.f. =.$30.00
. I. f. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I. f. = $50.00
I. f. @ $0. 50 = $
Additional
E.
Utility Repair Excavations @$10.00. = $
No.
Repai rs 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 Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with .this application.
SUPERINTENDENT OF HIGHWAYS
TOWN 0 OUTHOLD, NEW YORK
~...<
acobs
1('-..2~ -9 9
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.
0-39
Page 2 of 3
P4'-'" 0011 -~3''3QOo-3. 1"16 ~.u
.. RESIDENTIAL GAS REQUEST FORM
~eySpan Gas Corp. dlb/a/Brookly ion
\ Is Gas Capacity Request Required?.....
Is Regional EnglEngineering Req? ......
Are excess Attachment Charges Required?
WORK REQUIREMENTS
I No Work Required........ 0 New Gas Main w/Serviee ..... 0
! Upgrade MeteL.. ..........g Service Upgrade...... ............ 0
\ J\e\\' MeteL.. ...... ........fil Service Relocation............... 0
RiserlHeader Work........ f?/ Meter Relocation..... ........... 0
New Gas Service Laterall)l; Existing Building... YES ONO
,
SITE INFORMATION
THERMSIYR S uare Foota e Heated S
Large Meter :..Type Size
EXISTING LOAD Account # ~ 0 S <"'-1 0 ~
NEW SPACE HEATING ,/ 100000 lbOe Grid # 0\ '-I "Z.S'(~.
NEW WATER HEATING Regulator Size
NEW COOKING In-House Pressure
NEW DRYING New Rate Code
NEW PROCESSING Degree Days
TOTALS Dam. Factor
IMPORTANT NOTICE TO CUSTOMERS REQUIRING INSTALLATION OF A NEW BROOKLUYN UNION GAS PIPE
By Signing bclow, I am certifying that I am the owncr or have thc permission of the owncr to authorize thc installation of Brooklyn facilities at this properly. I
further understand that if Brooklyn Union installs a new gas pipe at my rcqucs~ and I do not usc the servicc that I must pey Brooklyn Union for the entire east ofthe
installation in accordance with KeySpan Gas Corp's d/b/a Brooklyn Union Gas Tarift Leaf No. 12A. Section 2B, 4.4 as approved by the Public Service
I Commission. I also understand that Brooklyn Union is not rcsponsible for repaving or landscaping on private properly. I have read and agree to the General
Requirements and conditions of the reverse side. .. . '
I .
\ Customer Name: (Print)
. CustomerlBU Agreement Date / J ~ I 1 - q?
-.--
"
~:
Macadam oNone
o Concrete oTree
D Dirt/Sod D Steep Incline
D DUG Electric
o Customer to remove/cut back bush
o Customer to install protection posts
o Customer to install pad \
New Service Diam ~
Meter 0 Inside
Existing Main Diam ..5L..-
~n:t~~
Mtl 5.lrl..
New Main
Diam
Length _
eter Order # 0
Work Order # 0
One Call Case #
GAS USE
No
DYes
/300
S=.>\'-"W
'Sl
--f,
--j"'tL des o.~ S-\-
CUSTOMER AUTHORIZATION
OF METER LOCATION
DYes
DYes
o Cesspool
OOil tank
D Sprinkler
o
presm..
o ..Remote
Pres ~-f'
Pres_
~
~
"
~
,,1/
-N-
/1'"
Street
o
\-!. \'N"\nY"\ ~C(L
COMMENTS
t
;:;
Q6\~-T~ ~
,;)..1) of. f-j.<J u-S P 0 11
IS
HSe Aa.....:5
hC/.S D
LRt1
Wf,ifc. wift. fore/"
sj f' IilJt ~/nJf(/,,-' ;,;e:5'-/
W R.oY\~ 0 iLC\ 0 'VI L 0[(.$
-S V p, : 00" 0 0 L
CHECK USAGE BTU INPUTIHR
,a;;l..
Date
Customer Sig:
BIU Rep Sig:
0__: C.M-.
1~{1.l..
~~