HomeMy WebLinkAboutFanning Rd
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Permit No. 02/
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File No.
TOWN OF SOUTHOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765-3140
Pc, t2>() Y- I 7 e,
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
:;)'10'(1 7]
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 ma,ke; necessary inspections of the job site.
Print or Type
1)
r-J ' 0,"::'
E: (YlA ,,..; .s T - r..~ \: dl..') r '-
Address
2)
Name of Owner of Premises
Address
3) \''i\'j.~\.3'g<-\\1,L... O...l(\...e""'iJ ?A,J.J,">/r f!..P d-7S't;% YrulSi-
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other"Town permits may be required.
No 'of'
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
.~l~
Signature of licant
l'2,~\'3\ctcy
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
;;) '-10 Y'7 . Y.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
tota I 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. 1-/Service Connections
No.
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ clO, Q.)
~
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I. f. @ $0.10 - $
;(G
~
'15- tP
~
Additional
C. Excavations. 18" 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
Utility Repair Excavations @$10.00 = $
E.
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
~1Z~~kt..V-u Ilv/IU) GIT-S
SUPERINTENDENT OF HIGHWAYS
TOWN 0 OUTHOLD, NEW YO
1-2 - / J' -ff1jJ.
Date
Received by the Town Clerk /02 -15- '1->>
Date
Permit Issued\. /OZ'/f,. 77
Date
Permit No.
obi
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
d- "-( (., ((7 '1 ~
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
I nspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
I B - Improper barricades
lL - Improper -Iights-
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
RESIDENTIAL GAS REQUEST FORM
KeySpan Gas Corp. dlblal Brooklyn Union
CHECK USAGE BTU INPUTIHR THERMSIYR S, uare Foola e Ile:lled S lace -
Large MeIer :..Type Size
EXISTING LOAD Accouul #
NEW SPACE HEATING / S-8 Grid #
NEW WATER HEATING 2.<>-0 Rcgul:lIOr Size
NEW COOKING 110 In-House Pressure
NEW DRYING 0 New Rale Code
NEW PROCESSING Degree Days
TOTALS tnn:.> 00111. r:lClor . 3D
IMPORTANT NOTICE TO CUSTOMERS REQUI UNG INSTALLATION OF A NEW BIlOOKLUYN UNION GAS PIPE
By Signing below. I am certifying that I am lhe owner or hnvc Ihe permission of the owner 10 authorize lhc inslallalion uf Brooklyn [aeililics allhis properly. I
further understand Ihat if Brooklyn Union insllllls a new gas pipe almy reqllesl, and I do flotusc the service IhalI IIltlst pay IlrooklYIl Union fur llle elllire cosl of the
instnllalion in accordantc with KcySpan Gas Corp.s d/b/a Brooklyn Union Gas Tarin: Leaf No. J2A. Section 2B, -1.4 as npprovcd by Ihc Public Service
Commission. I also undersland Iha' Urooklyn Upion is nnl .espon,ihle for r~vln ,d fil' 01 riv. properly. \-;!:.!lve read and agree 10 Ihe General
Requircmenlund eondilionsof,he reverse side. \d-- '\'\\ ~d ~,L \'f\O ~:"'()~l~~
Cuslomer Name: (print) lWloa~ rvI,rl:a,I FPr1{'u>- ClIslol1lerSig: de U J Dale /1 /;& /99
ClIstomerlBU Agreemenl D:lle . I h / at:> DIU Rep Si~:~'f &.. I '
\
f:
NT' I (0
ONTRACTORPIIONE
GerlbCiT 7;).,;;) -~. 2>
SERVICE ~ NIS . 0 S1S 0 E1S 0 W/S OF
LOCATION 275 nllo N/O 0 S/O )Ii E10 0 W/O
BUSINESS REQUIREMENTS
Is Gas Capacily Requesl Required?.. ...
Is Regional EnglEngincering Req? ... ...
Arc excess Allachmenl Charges Required?
o
D Yes
~NO 0 Yes
~o DYes
WORK REQUIREMENTS
No Work Required........ 0 New Gas Main w/Service ..... 0
Upgrade MeIer... .......... D Service Upgrade...... ............ D
New Meier...... ...........)( Service.Relocalion..,... ...... ... 0
RiserlHcader Work........ D MeIer Relocation... ... ....... .... D
New Gas Service Lalera Existing Building... DYES )NO
SITE INFORMATION
Mac:ldam
Concrete
Dirt/Sod
DNone
DTree
DSleep Incline
DUG Electric
Cuslomer 10 remove/cut back bush
Cuslomer 10 install proleclion posls
o Customer to install pad I(
New Service Diam -L
Meier 0 Inside
Existing Main Diam ~
o Ccsspool
DOillank
o Sprinklcr
D
Pres~
O..Remole
Prcs c'b
. New Main
LengOIJh
~ Outside
MII~
Length -=-
Pres_
Diam
Work Order U
One Call Case #
GAS USE
MeIer Order 1/
ZU' 1/ '1 &,
PLEASE INDICATE STAGE OF CONSTRUCTION
PLEASE CIlECK C\ . .
o Found.1tion 8""'Frnme-a 0 Enclosed
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CUSTOMERAUTIIORI ION
OF METER LOCAl' ON
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COMMENTS
Pi4.Ce. S....r..,;.:.e. 0...> -<<.... l.6-t ~:,k o~ t<-.....
hll.....~ be"';",i. ~ ck~~y' ^bo'"'-'t \6'
!="ro",- le-P-t ,<=."0 r. cOr-..n~ 01=' 1\.t.hc.r.-e..
G",-::,,~ IccA'eO "..., "'^'- <r~:.l.Q.. 0 F
I=p."'....;,.>~ \?oi300..
( /:v;~ rr; y /-he ZZclS
CPtu ~ij?q -# l' ~,.y - /;,2 1.( d.
Over~.!. GlUe....
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MARKETSPAN CORP.& SUBSIDIARIES
PERMIT ACCOUNT 2
448 MAIN STREET
PATCHOGUE, NY 11772
691
PAY
TO THE
ORDER OF
DATE i;)- /;,1 J ~1 '-32/210
$.~
DOLLARS I'!I :a:?_'::'
FOR
'Heel
29941 Patchogue Ojfire
Patchogue, New York JJ772
,9 WoO Y r") f 3
11'000 I; 9 loll'
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1:0210000:1 2 21:
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ELIZABETH A. NEVILLE, TOWN CLERK RECEIPT 0765 2 8
Town of Southold
Southold, New York 11971 ~ Or:!
Phone: 516.765-1800 DATE . -<t..' ;.10------ 19.1L...
RECEIVED OF: LfY)ra->rPp.f-- "'(OWl--' (i.Q?p r---- otfe--t. $_!L~tJ9_
FOR tf d.-/ 14~.Iu.-}r;,r -4:CU}a.{L..-ui- f2t211.1- / !J-L/)/YkJ-/...e..
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