HomeMy WebLinkAbout2255 Wickham Ave
File No.
36
30
-Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic . Lane
Peconic, New York 11958
(516) 765'-3140
:257Jrfl-cl P.tJ.(60~ 17t=>
If E C II V~LlCATlON/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
;1'15 co a ;// 75(
FEB 2 2 2000
"v1l",OiG APPLICATION IS HEREBY made to the Superiritendent of Highways of the Town
ofr~""'tk 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)
, ,->
G-
1-
Lfl F t114,- -S;
Address
,ct(j~
2)
Name of Owner of Premises
Address
3) i t.;,<-Lf tk/ILlo ddS~ 1.J\c.~klt-r-~ ,(V\."Ul~Ll<-
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction lo~ated within 75 feet of tidal wetlands? *Yes_No '(
*If yes, other-jown permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~reif~
g!d-;r/o:-
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.
Tax Map: Section
, Slock
, Lot
6)
7)
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:
\
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 provided:
or Certified Check
provided in the
2 years or
3 years
14)
Fees for applications and permits:
A 1. ~/Service Connections
No.
A2. /Additional Excavations same service @ $10.00 = $
r::ro:-
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ,;)0. (p
B. Excavations 18" in depth of less:
0-100 I.f. = $10.00
I.f. @ $0.10 ~$
;1' 'I ~"o
L-.. J
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
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.
Clerk of the Town
tG
to
NDENT OF HIGHWAYS
OUTHOLD. NEW YORK
. Jacobs
C). ::2.- - 00
Date
Received by the Town Clerk
J&.! ,e,0 /00
Date
Permit Issued, ~!.2c0/cc;
Date
Permit No.
3{)
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
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~~;;~ -----CCiMMERCiAUlNDUSTRIAL GAsilli'ejlJEST FORM---un------
"I Un_ KtjSpon GRS Corp. d!blnJ Brooklyn Union
t-&WJ'~'~~f /-'-'--- '-7';) 7;;'V-~j( Vr . (!J)lli!-fo"'" '" /. IIJ"Er .;'QJ'~':;Qd.Q
c7'10/!..(C ('--,v/'JJl.(' ()J//'r VJ.c.,,1.L1d:::...-. '_. ~I/...oJ--!t- "" 7 1 /
, ~AnD"-,," ~ I,. T-O"-1'.A" '-/'" I Drl; q ,"\
2?-~,~vI t/C:;1'/},-h ,(ve .____ 1'/ 1J'01 I <-<-Cr<: L'-' 0-
HAq.NAMI; / /' 'UL!,W,F:,srHON'_ . _ --.-.-- "'KlljkCrMORNAhI[,() t1 tJ~--
1:-11 0 (l.t: ( /\) /U /i O'--f-/ I fL '" / G i 'Il ..:, ~( I P V"-""- n,
I C()NTRA~T---- .-- .,-.- -c6NTRAClOH PHONE WOll::CT MGR I'AGtR 1/ 5.
I SERVlCB 0 N/S ~ S/S ci EJS - -- PLEASE INDICATE STAGE OF corsmuCTIO'iT7.21..::..:f
~ W/S Of LJ i d< ev.-.. 11< EO PLEASE CHECK
i LOCATION _ /0 FT' 0' NlO [] 90 ---600 0 FOUT1[\;JliOc\ [J framed t>i Endo",1
I OW/O._BAlD1- ;l..L_~d' -';>
f--- " BUSINESS REQUIR.!:Ml-:Nl'S- f 0" w'!--i() . '"
hs Ga' CIlp..'lClty RcquaL RequIred?...., ONo t8r'-yc.~ ~
Ii I' l\q;ion;,1 EnrJEn!lneerinr. Rc.q? ." ", ~No ~Ycs "
16 AccounlDcpo,ilcd Required?".." t6No 0 y", '..>
/ ;'h
I Arc c:<c,,,, A\\;lchment Char!", Required? ilINo 0 y~~_ f';'
i WURK RlQUIREMENT5 i"
I No Work Required......" 0 New Gas'Maln IVIServlce ..." C
I UPir*dcMctcr"..""..".O Service UPJmdc.""... 0
: New MeIer,,,.,. ............P'( Service Rclocalicn... .., [J
!.JIb
CVSTOMl:R AliTi:fOIUZATIC)---N---'--
OF METER LOCATION
\,
-i-F>-- /_
1(:
()
~-l
("::~
"
RlscrlHe..1dcr Work.., .,... 0
I New Gas Scrvk:e utcraJ 151
Meter Rc.J0C3lion"... ...........0
Exilling Building ..1Ic(YEs 0 NO
Slrt;ct
w icLhOJ\1
/tve
~
V)
SITE TNFOllMATION--'
~ M10l.d1.m ---------oN~lle
a COIlC<<\e OT,cc
g(DIrtfSod OStccp lncline
o OUG Eledric
o Customer 10 rcmavc.lcut bJck Mh
o CUl>(omer to install protection posts
o CUIIOmer 10 tn,"'11 pad ~" 1 r ,- 6 #1
, New Service DL1m D_ l<nr,\l,::::>":?" Pr"___~
, Meler 0 Inside ',- 0 Outsidc 0 RCll1()lijfl
Existing M,,;n Di,m.3...- Mil S't'L~. P'e'....Jz...O'...3.
New Mnin Di:lnl ungtl1 Pres " :,' ;' r' / ) f: !, ':r .I I ) !-
e '~mN~'~O': ,ru '~o.':m' - r- "'''OO^, -f:':::" ~;~ ,,"
: NEWSPACEl-illATING . ---- -- Grid" ~ /01'.05-':>">-")'-'
:' NEW WATER HEATING 3J.-;).., 12.(;,-0 ~::..::.. '--j 7' S'Q . -- J\c~ul'lo' SI1.c ------,--,0' --
NEW CO KING In-House Pre>ll/T'C r; w. ( .
NEW DRY1NU-- 'I~ --- New RJIC COOc 1]1 () .--
- NEW PROCESSING --.. Degre< D.y. ' . --
TOTALS 31 J.. I 000'--:--- 'I..J SO _ Doi". FllClor / ~__<l<., 2(
IM.PORTANT NOTICt TO CUSTOM!:HS REQUIHING INSTALLA liON OF A N[W IlROOKLUYN UNION GAS PI]'!:
Dy Si'l\in; below, I Ull ~crtir);t1, lh'l 11m IhQ olVnC'r Of h,l'r !he rcrminior. oC Ihe OW1">1:1 \0 'lllhorTlC lh" in:\ltllJllion o( Orooi:1Yl1 rncllili" I' lhh plcpeny I
rur1hcr undcIlland lbal if Droo~lyn Union irWi1II.~. nCI~ GB' pipe ~1l1\Y l'~qt!e_~, OtH:' I do n~l u\c lhe .l.-Crvitc lhnll mU~1 pcy Drr){1l:lyn Unloll ror lhc cnlirc {OSI c-flhc
! inllallltlon klaccorda/lec \.lIh KcySplln GIll Cor-r'~ dtblA Orco>:lyn Union Gll~ T~rif~ LCld }lo. 12t>-~ Section 2n. ~Jl 111 Ipproycd by th~ J'ublic S<!y;~t
i Colt1minlon. J .\w undcnlsmd Iha! Oroot:l)11 Unioll b not rc.~rC1t1siblc rur r~l'~viroZ or 1~l'\d"~I'I';!lS orl rriY~IO pro~r1y. 1 h'I'C ICld cnd ~~fCC \0 the Olncrll
1 Rcqlllrcmclb Ind Condlllo/U of Ihe rQVtflC Ildt.
, CUltornor Nallle: (Print);:: ~tUlle.1{;k IV ~1 '(~ ~IC\I'IO\l\Cr SJg.__ul (J l( fJ./l""'(LCGYc..u:c
f' 1",._._.mTl ~ ,....,.~''''''f T'1-,lr ? /0(') (1 nl1.J RC"p Slfr '....._~-}--n .AOoyL
OCc5Ipooi
OOil\:lI1J(
[J Sprinkler
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COMMEN_TS
f)e.ose, fROVI'cte.-
)(. Sd-,~p... to f(1..j)iJ"d.e.
on:::J K I'd! It / ~ 7583 if
G- HD
(jYl~
Iv.O. #::--
Ild(/
D,lo L;.J:____
Date: 02/22/00
Transaction(s):
1 Permits
Check#: 754
Name:
Brooklyn, Union Gas
4
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
754
Subtotal
$45.00
$45.00
InternallD: 2560