HomeMy WebLinkAboutLaurelwood Dr
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconi!=.>Lane
Peconic, New York 11958
RlClWii> (516) 765'-3140
11'1<;' 00 . P.O. l2>o~ /7t?>
.JAM 2eplOO~ATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
{.L iF 71t. d'l [r / d .03
.t~
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, ordinan.ces, codes and regulations, and to permit
authorized inspectors to make: necessary..inspections of the job site.
Permit No. ,}~
File No. 0~
.
Print or Type
1) Brooklyn Union Gas East
Name of Applicant
448 >East Main St. l'atch6~ue. N.Y. 11772
Address
2)
Name of Owner of Premises
Address
3) LoT
Work
L..Avl.Re(t-JOd,/J cJ.. .L,4A....c.(I~l. TV "~STt911
Description and Location (Street Number, Hamlet, Cross Stree
''<.
(a) Is construction los;ated within 75. feet of tidal wetlands? *y es _No XXXX
*If yes, other'!own permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~ ~~~~
. ..... Signature of I dmt
/~/d'O()
Date
5) a) Attach plot plan showing location of proposed..el<"savation and relationship to
adjoining premises or publicstre.ets or areas, and giving a detailed descrip-
tion of layout of excava tion.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by thisapplicatioh may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
Tax Map: Section
, Block
.. , Lot
6)
7)
8)
Starting Date:
.
Completion Date
Work Schedule:
,"(,'
Phase
Completion Date
9)
Excavation. . . . . . . . . . . . . . . . . . . ..". .. ~\~ . . . . . . . . . . . . . . . . .
Facility Installation.. ........ ......;.................
Backfill & Compaction..............................
Pavement Replacement..........,...................
Under which authority is the appliCation made:
Estimated Cost of Proposed Work: $
10)
11)
Remarks:
\.
0-39
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
or Certified Check
provided in the
provided:
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 = $ r:lc),O:;-
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I. f. @ $0.10 - $
Additional
C. Excavations-..l.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.
Repai rs same serv ice @ $5.00 = $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *"
j7)fY>rL y.s-: GO
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.
SU.PERINTENDENT OF HIGHWAYS
TOWN 0 OUTHOLD. NEW YORK
/- de; r OD
Date
Received by the Town Clerk
/- .;l{,~C>C)
Date
Permit Issued,. 1- r:Z.o - ()O
Date
Permit No.
oz,{;,
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hqur 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
IN SPECTOR'S
RECORD
Inspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
lith
(To Permit Clerk)
-~~.
REMARKS
CODE
IB - Improper barricades
lL - Improper-lights"
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building undel' Construction
WIP - Work in" progress
DB - Improper backfill" (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
\"
0-39
Page 3 of 3
~51t
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00 \ ~'~ '3DC)(J d.. ___Els~ ____
RESIDENTIAL GAS REQUEST FORM
KcySpan Gas Corp. d/b/a/ Brooklyn Union
\<:e
LAv.t2e.lu::r:r:r:i 6,-; ,,~
~o;.L S. ';.v.- lI~tI! //72
CONTRACTORPIIONE
5~
Oqoo
. ~~ ; \ uu REr lIoNrS1
ZIr I /9~
PLEASE INDICATE STAGE OF CONSTRUCTION
PLEASE CIIECK
o Found.1tion 0 Framed 'p(~.9~losed
DUSINESS PIIONE
LOCATION
~ W/S OF L ~1<<:rr>A ~;,..e...
/0 0 S/O 0 EtO 0 W/O ?eQ..<:>"",,,,",
BUSINESS REQUIREMENTS
Is Gas Capaeily Requesl Required?..... ONo Yes
Is Regional EnglEngineering Req? ...... 0 Yes
Arc excess Atlaehment Chargcs Rcquircd? 0 Yes
WORK REQUIREMENTS
No Work Required........ 0 New Gas Main w/Service ..... D
Upgrade MeIer... .......... 0 Scrvice Upgrade...... ............ D
New MeIer...... ...........)( Service.Relocalion...... .........0
Risern-Icader Work........ 0 MeIer Relocation... ... ....... .... 0
New Gas Service Lateral}/O Existing Building... o YES 0
SITE INFORMATION
Macadam D None
Concrete 0 Tree
~Dil1lSod DSteep Ineline
a aUG Electric
a Cuslomer to remove/cuI back bush
o Cuslomer to inslall proleclion poSIS
O' Cuslomer 10 inslall pad "
New Service Diam ~
MeIer
Existing Main
LengUI~
a Oulside
Mtl PiAl:.tv-
o Inside
O. .-,,1\
Iam~
.New Main Oiam
Work Order /I
One Call Case /I
GAS USE
LengUI
Meier Order II
CHECK USAGE
a Cesspool
OOillank
a Sprinkler
a
Pres ~O
D..Remole
Pres~
Pres -
BTU INPUTfl-1R
~
~
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CUSTOMER AUTHORIZATION
OF METER LOCATION
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Pet"',,:c. ~y Q.i..H:lt .
COMMENTS
p\CU,(... TSOS\,)\c.(" I'~'" lU:+~....+
CorN'=- ClIO ~..(5e.e..IY\I"'I?fd'C.ck~~\-0
c,A.'::. \~ \,,<.p,\<J. 0.... ~ r-J<IAI2......\~,.
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CF ~l~ ~;-x...
00 ~ 4$SJ ;;tC'~o
oo?>/54103D
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S._'
THERMSNR
2iS
EXISTING LOAD
NEWSPACEHEATING /(;O,t7UO 23/G
NEW WATER HEATING ' Regulalor Size
NEW COOKING s; In-House Pressure
NEW DRYING ~ </0 New Rale Code
NEW PROCESSING Degree Days
TOTALS ::J7'-1tlDD 00111. Faclor
IMPORTANT NOTICE TO CUSTOMERS REQUlR NG INSTALLATION OF A NEW BROOKLUYN UNION GAS PIPE
By Signing bc:low, I am ccr1ifying that I om lhe owner or have lhe permi."sion of lhe owner to aulhorize Ihe insln!lalion of Brooklyn faeililies allhis properly. I
rurlher understand Ihat irlJruoklyn Union instnlls a new 8:15 pipe at my re(luesl, and I do uol use Ihe 5ervicc Ih:11I ltIt1s1 Ilay Brooklyn Union for Ihe clltire cost orlhe
inslullalion in accordance wilh KcySpan Gas Corp's d/b/a Brooklyn Union Gas "rariO: Leaf No. 12A, Seelion 2B, .IA as approvcd by (he Public Service
Commission. I also understand that lJrooklyn Union i!; 1101 responsible for repning or 1:.Illdsc:apil1g on pri\'alc properly. I Imve read ond ogree 10 Ihe Gencral
Requiremenls and con_dilions of lhe reverse side.
CuslomcrName:(print) L?", ,a.,g,,(t:V
Cuslomer/BU Ag!eement Dale I ).fJt,/.:zc-c.>o
Date
/ A/.u.o-o
CustomerSig: /VII ~ /LU/
BIU Rep Sig:' ~ ;11, ?'It-/'
./'
;J/J..
'.
716
MARKETSPANCQRP.8! SUBSIDIARIES
PERMIT ACCOUNT 2
448 MAIN STREET
PATCHOGUE, NY 11772
1-32/210
FOR
DATE
PAY
TOlliE
ORDER OF
DOLLARS ffI='::"
eBBb ~
~-~-- -'!
/lIP,!,
EUZABETH A. NEVILLE, TOWN CLERK RECEIPT 07 7 0 07
Town of Southold
Soulhold, New York 11971 0
Phone: 516-765-1800 DATE (0' V/J _o2c:rcJ
{I
RECEIVED OF: Yi ) u '[ IV.J /)CL-"1-~---- $ "/s-:- /Po
ll=-9C)~ / ~ 4f / . _ EJu/Yf~ - /-1 A - - L ~
FOR ;0:n1u~_:' d~' i',-- .__~ka~
D~ ~
WCRECK f/- 7/ h BY '- -' ~ / "--=1------