HomeMy WebLinkAboutNew Suffolk Lane & Cedar Rd
Permit NO.:J. S-
o ~ TOWN OF SOUTHOLD
FiJe No. cY~ HIGHWAY DEPARTMENT
Peconic Lane
~ Peconic, New York 11958
11 jtl f (516) 765'-3140
Jf\N 20 2.9-00 p. o. /2>".,... I 7 e:,
U1€' 7/)APPLlCATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
.t ~ c;J \(7 &> y. 9 '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 m1ake: necessary. inspections of the job site.
Print or Type
1) Brooklyn Union Gas East
Name of Applicant
448 East M.ain St. Patchogue. N,Y. 11772
Address
2)
Name of Owner of Premises
Address
3) NEe.- SL-ul"r"dU:: L", -+ C<:JAd M c/c'S.-<'VL'.,sUO 11..).-, A71"1c 1.~d1"
Work Description and Location (Street Number, Hamlet, Cross Street)
(a)
Is construction located within 75 feet of tidal wetlands? *Yes_No xxxx
*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.
~-L-.l r-~^" o-~-
Signature of I dmt
j
j-j'L-OU
Date
5) a) Attach plot plan showing location of proposed- elfcavation 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
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:
\"
D-39
Page 1 of 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.
I 1 Additional Excavations same
No.
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ dO- G-0
A2.
service @ $10.00 = $
/c!
~~
B. Excavations 18" in depth Or less:
0-100 I.f. = $10.00
I. f. @ $0. 10 - $
C.
Additional
Excavations--1-8" in depth to 5' in depth:
0-100 I. f. =- $30.00
c;1 I 0 . I. f. @ $0. 30 = $ G, 3. (;J
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 = $
u'
SO
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.
* * *
77) jI4 I
I ,-/,r- c:~
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.
ENT OF HIGHWAYS
OUTHOLD, NEW YORK
,
/~o?o ~ ~iJ
Date
Received by the Town Clerk
j-02tJ-OCJ
Date
Permit Issued\ ! -;20- Co
Date
Permit No.
ciS-
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
INSPECTOR'S
RECORD
Inspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
.---
REMARKS
CODE
IB - 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
FC.I7D.I.sS
PREPAREDBY K~,jiJJ SCHulz /!,,r 7SJ-SNo
DATE , I rz../ "LaD\?
SUBJECT -k'vJN /J+- ~<L/1IDLb !le,ui"'-
tJA1l/ L J.._ ED Jc.di?!:-_~~u_
14 /)0 If.Ir: 5 <to c.;; blltS
70,)",: f!....../i.1I~6.tJL-
-
..-------.....---........--
----.
ill-"/)
1
~.
;t...1
L.;
",
:I L J" PLs-!_
I - lob'
%\
~
~-
l>
':'l 1-;\ ~\~) ::-\
::::. "". f'-l r-i t;'
~~ ~ ~ -,
~ ~~ 'Z-
~ !,\ t:\ 1-.)
f\' IS"L--.' ~
~, " .~
\.,,) ~) ......
I"'~
""
~
c::-
NtW ~ u!ll>L'JL
3."s-rL - -
I
PG._
z0./7(,<{-930
W.O.#
ACCT.# ~.K' y"j tilt;',. GAJ
r---- z
/
~
~
~
"
-~
'...;
;:.,:
ilt;
!,
'I
-,'-
;1
I
~
1
"-
0\, LA,JL
T
Request for ~
4J...,.:nllJl..b Permit FEE* $
Permit required to open!
LA"'l.
t
, ,
of'
fl4')(t./'K3'
,'..1 'Tfh.... I' !r-v{..";>
t ~";) .M<... $ tZf-r
112.
REQUEST FOR PERMIT
&f.iI;-h1 t:.
~
s''+D~ul4.- M-f:A I
(7Li- Nc.-/..
C- c.v,4,{ s
,'~
iAJ I 77-1 ..2 aut ~CLS'
/>, ~/C!rloGdL
111.<=..,J
THr....
p
Permit Requested By:
TO /1.00
Work Request # 24-
-f~o
Type of Road
FC~1145.6-SS
Return Permit To:
ew Business Department
&Ms'S.
MiSr, "Ec
o To be billed
711 ~ w/..r "I ft.: 1.)" Ju41. <.,<
liT 71(~
~,,;l.7H >.J7i'LS~"C/-'c-J
W(.$lwA-tl:>
M- 'L-,4 I-~ I--
/t /I~L
6->L TIft:.. tJls
3 If)' t~?:>/;;,r-
u.JlJ ~~
('J & 'J.4J<S
p.
o a.N. 0 Cent. 0 W.S.
E.S.
Gas Service for
o No fee
o Underground Lines Department
DOper. Plan. & Cant. Center
MARKETlSPAN CORP.& SUBSIDIARIES
PERMIT ACCOUNT 2
, 448 MAIN STREET
PATCHOGUE, NY 11n2
715
PAY
TO THE
ORDER2]2
,.J d~
....dL3
~FJeet
299<11 PatcJwpe Offire
Paldwgue, New York 11772
d Y ') to V - 9' '5
~ dL--<_ ~W
DATE
1/;.;1/00
1-32/210
FOR
~'f
2-JcC, -?S-
$j 'If ~
ot.~llARS lfI='::'-
~~~ &,::ll/J ) ____...
II.DDD? ~ 511. ':0 2 ~DDD:I 2 21:
-- -- --~ ,-- -~~"--~- -- ,.~ ~-
-----=--- --~~~_~_=_~----~2--:-------
~
ELIZABETH A. NEVillE, TOWN CLERK RECEIPT 07700 6
Town of Southold
Southold, New York 11971
Phone: 516-765-1800 DATE ,J V---1 ' _~~__ = C>bo:>
RECEIVED OF: Yl) (,//r"p-",;L4yO~ QJSr? j L___dx i2~
"':n:;':I:~~~~::"t~: .~~
o CASH
~ECK #- 7/~ BY /~~'-' ,