HomeMy WebLinkAbout1210 Country Club Dr
File No.
3;L-
Permit No; -3 '-
Ii ~
TOWN OF SbUTHOLD
HIGHWAY DEPARTMENT
_ __,0 .~_' ... Peconic.'Lane
^'. -- .. . Peconic; New ,york 11958
I' eEl XE D (516) 765'-3140
fI-!f;u/ J-U P. o. t2>o~ I 76 .
MAR 3 -_'CATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
iOuttlokllown aerk
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APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excaviltlon 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 make: necessary:'fnspections of the job site.
\
Print or Type
1) Brooklyn Union Gas East
Name of Applicant
448 East' Main St. PatchOgue . N.Y. 11772
Address
2)
Name of Owner of Premises
Address
3)
1......... 'UA. . C~ T ck., <. <: _
Location (5 reet. Number, Hamlet, ross Street)
(a) Is construction lo):ated 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.
~~1~/Y\-~__
. .... . Signature of I cant
Date
5) a) Attach plot plan showing location:of proposed<elits;avation and relationship to
adjoining premises or public' stre.ets or areas, and' giving a detailed descrip-
tion of layout of excavation. "
b) Attach all ofner necessary permits and licenses for this project.
c) Work covered by this applicatiollmay 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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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
-.114)
Fees for applications and permits:
A 1. /Service Connections.
~
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $
No.
B. Excavations 18" in depth Or less:
0-100 I.f. = $10.00
I. f. @ $0. 10 -$
Additional
C. Excavations...l8" in depth to 5' in depth:
0-100 I.f. =-$30.00
.;2&S-~ I. f. @ $0.30 = $7 '9& JV
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
1.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.
* * *
-roT'A-L ?fcf a (. ~
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: '-/.!V,.A~ I/~,,;:', 9hA /
in accordance with .this application. '.
SUPERINTENDENT OF HIGHWAYS
4..w N. F SOUTHOLD" NEW YORK
'-----~/'~~ ~
Raymon . Jacobs
:? ~ .2. - CSo
Date
Received by the Town Clerk
3/0;100
Date
Permit Issued\. ..3/aho
Oa te
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
REQUEST FOR PERMIT
. Request for O......:-r1-l "LJL
Permit FEE' $
Permit required to open!
/l <f- ')(4' K 3' ;3iH'k(f- P?-L 7111:.. wj.r pi ;tI~s (P"Jf ,d 71k
-€.7JM f9! f7/!:. ;1wr;> ~E,4) +A81A- ~c.i So u7}(' IP-X. 'till:.. wj.! ./' #~S
~ f-. ,).; '111L U,4fS; ~ s"II Ie '" ~ 11.. ' uJ; 711 /I "'!.:..,S /1.1:. . .,fl./.-T' ,IJd.,u..f.J
-r;I~ t'i1--;L/s2t!--Fwt. &..-<,/7"il,/ t!u.6 At, ~Lso /(J "),6- ,,;;lbIpl
:JiI 11IL (,;,4.s.s ~/I ,..... fHE. ,..js of- wjs ~I {l~~ aLqlJ lJ,6
./~ l 17(PD' ,,... ~/(e6UL.'
Permit Requested By:
t-II",~
o O.N. 0 Cent. 0 W.S.
LS.
TD
1300
Type of Road
Gas Service for
'"" 0 Disbursement to be made out of petty cash
Charge account #
Work Request #
o To be billed
o No fee
Return Permit To:
ew Business Department
o Underground Lines Department
DOper. Plan. & Cant. Center
FC.1145.6-SS
GENERAL NOTES
All Mains to be SDR 11 Medium Density Plastic and have an operating pressure of 60#'s
Install 896' of 4" Plst Main with 1-4" Valve from the existing 2" Steel Valve on Moores Lane (replacing 149' of existing 2" main)
Install 1760' of 2" Plst Main with 2-2" Plst Valve on Country Club Drive
Close Valve #3382, install a 2" Transition Ftg, 2'; x 4" Plst Reducer & a 4" Electrofuse Cplg for the tie-in on Moores Lane
All Mains to be trenched in Grass or Dirt Areas wherever possible
4" Valve to be installed per CS's-11105 & 11112
All 2" Valves to be installed per CS's-11105 & 11111
Install Valve Location Markers For Valves in Grass areas per CS-11101
Any trench in paved areas to be filled with temporary patch
All Mains to be installed per CS's-11800, 11001, 11004, 11005, 11014 & 11016
Test Holes to be dug when crossing other Underground Facilities to determine needed clearances
CREWS TO USE DISCRETION IN REGARDS TO MISSILlNG OR TRENCHING INDIVIDUAL DRIVEWAY CROSSINGS
(RECOMMENDED TO MISSILE ANY DRIVEWAY WITH BELGIAN BLOCK BORDER)
MISSILE OR DIRECTIONAL BORE ALL ROAD CROSSINGS
GAS SERVICES TO HOUSES TO BE INSTALLED ON JOB NAME :Judy Foreman
SEPERATE WORK ORDER #IS ISSUED BY SALES DEPT. STREET(S) : 1210 Country Club Drive
JOB TOWN: Cutchogue
GRIDS\ Install 896' of 4" HP MD Plst GM,
50' 200' Install 1760' of 2" HP MD Plst GM
101-35-3 101-10
101-36-1
101-36-3
MEP #1024
Keyspan Energy Corp. d.b.a. Brooklyn Union Gas
IGas Construction & Maintenance Services I SCAlE
AREA 448 MAIN ST.
24 PATCHOGUE NEW YORK None
DRAWN BY, DATE W.O.#
KEVIN SCHUTZ 2/26/2000 24957-030
DWG.1 OF6 PERMITS Town T1300CT 8.1.#2330043
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