HomeMy WebLinkAbout22655 Soundview Ave
Per~it No. d. f
File No. Oi 'f
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic, New York 11958
(516) 765'-3140
Po. f2,oY- /7e.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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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 mlake; necessarY"Inspections of the job site.
Print or Type
1)
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of Applicant
LAw 10-
y YeP f" /71 ;,J JT 4r r(j~
Address
2)
Name of Owner of Premises Address
JI'..J .s \)0., II G-M l\) ;:l d- <.0'::; S- S c;)v.. ~~ 0 \ e u A-e_ ~ .Lh i\.-..._A.J
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *YeS_NO~
*If yes, other-Town permits may be required.
3)
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
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Signature of A l}fant
I - I c) . CJ/)
Date
5) a) Attach plot plan showing location of proposed. excavation and relationship to
adjoining premises or publicstre,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)
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) Rema rks:
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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. /Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ,},O
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 iss.uance 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
~~..) U/r--u1'-- ~-<V
SUPER IN ENDENT OF H IGHWA YS
TOWN F. SOUTHOLD, NEW YORK
bs
J -/6~oz)
Date
Received by the Town Clerk
I - / [) - Dc)
Date
Permit Issued,' / ~/^'_ - (J-")
Date
Permit No. 02 1-/
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.
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CONTRACTOR 1'1I0NE
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I'LEASE INDlCATt; STAGE 01' CONSTRUCTION
i'LEASE CIIECK
o Found.1lion 0 Framed)'! Enclosed
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NIS . 0 S1S 0 FJ 0 W/S OF
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BUSINESS REQUIREMENTS
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'1 Macadam 0 None
!l 0 Concrete OTrce
.~ tJ(' Dirt/Sod OStccp Inclinc
l {;'- OUG Elcctric
d 0 Customer to rcmove/cut back bush
jj 0 Customer to inslall protcction posts /
I .0 Customerto inslall pad " P\QLe. sm-o\ce. 2j \..:t ~w"" Le.t;:.l. '~'*
;1 New Service Diam I Length }50 Pres ~
1 ~. Cer '" <J<:. o~-\l.e... ~e.. .
::~ Meter 0 Inside Outside O..Remote
J E..,istingMain Diam Z II II ~I Pres~ OO'cl4 810030
:,1 ,New Main Diam LengUI Pres - 0 0 3 75 L./ " 0 3 D
1 Work Order II Meter Orderll 11 <::.rA c..< ('. II!. j;f
:1 One Call Casel ff,ss;13tr ;:,4l:t; 4-/'("J - .5'q.U/17 '?
.l GAS USE CHECK USAGE DTU INPUTIHR THERMSIYR SI uare Foota 'e llcated S lace 3S00
.j _. Large Meter :..TYJle Size Z. 7S"
1 EXISTING LOAD Account II ,
,I NEWSPACEHEATING ~5zo GridU
J NEW WATER ilEA TING Regutator Size
~
NEW COOKING / S'o In-House Pressure
NEW DRYING ~o New Rate Code
NEW PROCESSING Degree Days
TOTALS /IT7O Dom. r;lctor ':30
IMPORTANT NOTICE TO CUSTOMEUS UEQUIIUNG INSTALLATION OF A NEW nHOOKLUYN UNION GAS I'WE
By Signing below. I alii tU1ifying dull I am Ihe owner Of have the permission of Ihe owner In t1ulhorii'.c Ihe insliJlIlllion of nrou~IYll f.,eililies allhis properly. I
f"r,I.~lcr Ululersland IlIal irlhun1:ly" lJninn insllIlIs 0 IIC\V g:IS Ilipe lit my re(ltle~l. and I do 1I0t Ilse the service lh:llllllu~( flay llruul:lyn lJniunliJr l'le (Illire cosl nf Ihe
i,',lslallalion in accordance \Vilh Kcy5pan Gu.:'! Corp's dlb/a IJlUoldyn lJnion G,IIS Tarin: Leaf No. 12A. Section 21J. ,1.'1 liS IIflJlroved by the Public Service
Commission. I .Iso undersland lhat IJrool::lyn Union is nol responsible for repavillg or lundsellping 011 privole properly. I 'IDve read alld Itsree 10 (he Gencr.'
Rcquircmenll..nd condilions orlhe ie'verse side.
Is Gas Capacity Request Required?.....
Is Regional EnglEnglneering Req? ......
Arc excess Allachment Charges Required?
o
o Yes
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CUSTOM En AUTIIOIUZATlON
OF METER LOCATION
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o Yes
o Yes
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WORK REQUIREMENTS
No Work Required........ 0 New Gas Main w/Service ..... 0
Upgrade Meter... ..........0 Service Upgrade...... ............ 0
New Meter.................)(' Service Relocation...... .........0
RiserlHcader Work........ Meter Relocation... ..............0
New Gas Service Late Existing Building... DYES 0
SITE INFORMATION
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o Cesspool
oOil L'U1k
OSJlrinkler
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COMMENTS
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CuslomernlU Ag.reemenl Date
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Customer Name: (print)
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
Inspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
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REMARKS
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CODE
I B - Improper barri.cades
IL - Improper '1ights\
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
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