HomeMy WebLinkAbout1255 Kaleigh's Ct
Date: 02/10/00
Transaction(s):
Name:
1 Permits
Check#: 744
Brooklyn, Union Gas
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
744
Subtotal
$45.00
$45.00
Internal 10: 1921
Pe'rmit No: &..1"
File No. &.-9'
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
PeconicLane
;)'::0 c.... 003' Peconic, New York 11958
..J 0' r (516) 765'-31liO
RlClJfrei) PO. t2>(J~ I 7 E!:>
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
FER 1 {) 2000 ",
N i/6~
..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, ordin'ahces, codes and regulations, and to permit
authorized inspectors to m1ake: necessary ,inspections of the job site.
Print or Type
1)
t-..J UN.
licant
ST fA T(,^o t..~
2)
Name of Owner of Premises
Address
3)
i,s c r / "'/~
ion and Location (Street Number,
^'
(a) Is construction los;ated within 75 feet of tidal wetlands? *Yes No
*If yes, otherlown permits may be required.
li) Builder's License No.
Plumber's License No.
Electrician's License No.
Other T'rade's Li"cense No.
~ ~~~~~~.
, Signature of ~ Ii ant
8/<i ~
ate
5) a) Attach plot plan showing location of proposed.e,,'cavation and relationship to
adjoining premises or public stre,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)
7)
Tax Map: Section
Block
, Lot
Starting Date:
Completion Date
8) Work Schedule:
Phase
Excavation......... ................. ...............
.
Completion Date
Facility Installation.................................
Backfill & Compaction..............................
Pavement Replacement..........,...................
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. --1-IService Connections
No.
A2. IAdditional Excavations same service @ $10.00 = $
Nil":-
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ .l- 0 - c:.>
B. Excavations 18" in depth or: less:
0-100 I.f. = $10.00
I . f. @ $0. 10 -$
Additional
C. Excavations---lll" 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 issuance of permit.
* * *
Authorization is hereby granted to the Tgwn Clerk of the Town of ~outhold to
issue a Highway Excavation Permit to: ~/P) I-C/)'././/}'- AO"h1..J
in accordance with ,this application. __
SUpERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
d( - 10,..- 00
Date
Received by the Town Clerk
~-/O.OCJ
Date
Permit Issued, - ~ -10" 130
Date
Permit No.
aZ9
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
--- ._-.__.-._--'------_..._-_.,.._--~----_._.~_._--.,~ .--..----..-.-----..----
s Gas Cap.1cily Request Required?.....
s Regional EnglEngineering Req? ......
,re excess AUaehment Ch.1rges Required?
Macadam
"concrete
Dir1lSod
oNone
o Tree
o Steep Incline
DUG Electric
Cuslomer 10 remove/cut back bush
Cuslomer 10 install protection posts
Cuslomer to install pad II
," Service Diam I
ler
sting Main
v Main
rk Order II
, Call Case fI
GAS USE
Lenglh gO
)tV Outside
Mil 1I.45f,c-
o Inside
Djam~
CHECK USAGE
,merlBU Agreement Date
-zit,;. /d1J
RESlDENTIAL GAS REQUEST FORM
KeySpan Gas,Col'p. d/b/a/ B,'ooldyn Union
o
f f\Jo Yes
"
)l(No '0 Yes
,9(No 0 Yes
o Cesspool
oOil ~1nk
o Sprinkler
o
Pres~
o ..Remote
Pres~
Pres-=.....
BTU INPUTIHR
13/U Rep Sig:
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1I0ME 1'1I0NE. 'd j'LEASE INDICATE STAGI;OI' CONSTRUCTION
J l? 3..l-c. hS76 rLr.AsE CIIECK
/JUSINESS mON!; Q" Found.1lipn ~ Framed 0 Enclosed
, <'ol>1r ",-+eel I"d 'h .,., ,.
/~/, (T .
0'41.v e;, .q,l
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CUSTOMER AUTHORIZATION
OF METER LOCATION
WORK REQUIREMENTS
!o Work Required........ 0 New Gas Main w/Service .....0
'pgrade Meter... ...... ....p Service Upgrade.......... ........ 0
ew Meler...................k Service Relocalion...... ......... 0
iserlHc.1der Work... ..... 0 MeIer Relocation...... ........... 0
zw Gas Service Laieral Existing Building... oYES)~rNO
SITE INFORMATION
STING LOAD
Y SPACE HEATING " /35:tnro 20lb /1 _ .5-. Z.
V WATER HEATING V> -1fi<n:n) :2-ov Regul'llorSize .:5;<4,./"1_/
Y COOKING / / S'~t~ / /0 in-House Pressure .,C
V DRYING V 2 i'.ot::b rb New Rate Code
I PROCESSING Degree Days
ALS 7'1' c= 23 Dam. r:lctor jo
l'1PORTANT NOTICE TO CUSTOMEHS HEQUHING INSTALLATION OF A NEW llHOOKLUYN UNION GAS PIPE
'.ning below, I .'" certifying Ih.1 I .'" Ihe nWller or have Ihe per",i"ioll of Ihe oWller 10 .ulhorize Ihe iIlS,.II"lioll of BrooklYII f.eililies D'",is properly. I
r underslant.llhal i[fjruoklynlJllion in~lll"s a new g:l~ pipe ;11 illY rcqllesl, :lnd I UO lIn! IISC Ihe :;crvicc 1I1:l1 Imll:;( pay Ilruoldyn Union (or (he enlire eo~l o(lhe
alion in nceoruanec wilh KcySpan Gll~ Corp's d/b/ll Brooklyn Union Gas TariO: Lea( No. 12A. Seclioll 2B, 'IA a:; lIpproved by lhe Public Service
,ission. I .Iso unders'and Ih., Brooklyn Union is nol re'ponsible for rep"ving or '"ndseaping on pr,,,ale properly. I h.ve rea" nnd Dgree '0 Ihe General
stCdeo(~ncrlberr!S si i~L\ ~'?(\(\I 1",:1 '') ;0- --"-;-\'\z/ i~(', ('''',
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COMMENTS
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