HomeMy WebLinkAbout7390 Peconic Bay Blvd
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Permit No. c2 J
File No. (2 3
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'" 3140
P. O. (hoy- 17f>
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
d'-(~d}'o3
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 m1ake' necessary inspections of the job site.
. .
Print or Type
1)
B6<.o () \::::' \'-( t--J V- ~ '- (),-J Cr f\-A'
Name of Applicant
crl(J'-[' /J1J4,,.J S, -1A--1c1'(f4
Address
2)
Name of Owner of Premises
Address
3)
TO I J'Il5 E' Cd~,
Location (Street Number, Hamlet,. Cross
Lf [//1. L.A-<--/\ -e (
treet)
(a)
Is construction located within 7S feet of tidal wetlands? *Yes No ~
*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.
~~e ~~ant
/- 10 00
Date
5) a) Attach plot plan showing location of proposed- el<'cavation 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.
Tax Map: Section
, Block
, Lot
6)
7)
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:
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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. I /Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
~
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ .:J() . UJ
B. Excavations 18" in depth Or less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
Additional
C. Excavations~.1'8" 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 TowlLOf SO)ltho~d to
f3/7 -M.,4~9t-) (/ /'j / <J) k{~
/-/cJ- CJtp
Date
Received by the Town Clerk
/-ID-{)O
Date
Permit Issued,' I-I.. tJc:)
Date
Permit No.
000
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
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, I:l1'OOl':1)'Tl ~. ~
'Ofb~~l .V'. ..~ \ .L\
TO~IF;RN E q I
73'10
uSa ADDRESS
\lCE
~A TION
as Capacity Request Required?... ...
egional EnglEngineering Req? ......
excess Anachment Cha!:ges Required?
-... ~.~
o ElO 0
DYes
DYes
DYes
WORK REQUIREl\IE.
,York Required........ 0 New Gas Nlain \\1Seryice ..... 0
rade Meter... ...........9 Service Upgrade.................. 0
. Meter... ...............~ Ser.ice Relocation...... .........0
r/Header Work........ Meter Relocation... .............. 0
. Gas Ser.iceLateral ExistingBuilding... YES 01'0
S E INFORMATION
I
CHECK USAG.E I BTU INPtiTIHR I.THE.RMSfY...'R L~l1...uare Footaoe Heated S ace
I Large.Meter :..T)'jle Size
~tING LOAn I I Account #
I SPACE HEATING I Grid # () - 00-
I WATER HEATING I Regul~tor Size
I COOKING' . In-House Pressure
! DRYING I New Rate Code
, PROCESSING Degree Days
Ais . I 2-1, I..f . Dom. Factor
,IPORTANT NOTICE TO CUSTOMERS REQUIRING INSTALLATION OF A NEW BROOKLUYN UNION GAS PIPE
.ning below, I am eertif);n,that I am the owner or have the permission of the owner to authorize the installalion of Brookl)'ll faeili,ies at this propell)'. I
r undemand that if Brookl)'ll Union installs a new las pipe al my reques~ and I do notu.ethe servieethall musl pay Brookl).. Union for the enlire eo.t ofthe
ation in aeeordanee with KeySpan 0.. Corp's d/b/a Brookl)'ll Union 0... rarift'Leaf No.' 12A. Seetion 2B, 4.4 as approved by the Publie Sen'ice
,ission. I also understand that Brookl).. Union is not rosponsible for rep"'ins or t~nd.c.pins on pri''nte property. I have rend and asree to ,he Oeneral
rcments and conditio,!s oelhc rc\"crsc side.
0acadam ONone
~oncrete OTree
JirJSod 0 Steep Incline
. ..... .... ...... '..... .OllGElectri,c
:u~\Ol!lerlo reiri"O\'C!CUlllackjlush" .::.
::USlomer to install protection posts
::ustomer to install pad I .
. Service Diam ~
or 0 Inside
ting Main Diam ~~
le gth 2o'()
OWide
tl..)'fC.
Main
Diam
Length .
k Order #
Call Case #
GAS USE
Meter Order #
orner Name: (print)
-
.omerlau Agreement Dale
:;)- 1./.... () 0
o Cesspool
oOil t.an.l:
o Sprinkler
.0
.:.....,.:..
....'.
.....
.~~..
'Pres~ .
O..Remole
Pres/:t..:f.
Pres
Customer Sig:
B,IjJ Rep Sig:
f CO)iSTll.l;CTIO;ol
!C'
~.
n
. a.',
CUSTOMER AUTHORIZATION
OF lI-IETERLOCATION
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. Street
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COll!MENTS
GAs 'Sef-Vl C~. ~ -h(.e~
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cr Cl- s~')g ~'8
00-;;) 4-R b aO 3 0
00 37S3l., 030
(!AU: /VD, GO I 09
.AdA (IF
Date
1'1
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)
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REMARKS
CODE
IB - Improper barricades
IL - ImproperlightS\
ST - Sunken trench Or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in. progress
DB - Impropel" backfill. (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
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