HomeMy WebLinkAbout1250 Founders Path
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic.'Lane
Peconic, New York 11958
(516) 765""3140
P. O. t2>cy- ,75'
,
.' Permit No. .3/
File No. ,]/
I -, 8'y~.o3
QECEIVED
fEB1f~TION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
,.-.
~..rhold Town Clerk
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for thEilS'suance of an Excavation Permit ,.pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordin/mces or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinartces, codes and regulations, and to permit
authorized inspectors to make: necessary\inspections of the job site.
Print or Type
1) Brooklyn Union Gas East
Name of Applicant
448 ,East Main St, l'atchogue, N,Y, 11772
Address
2)
Name of Owner of Premises
Address
3) Ic950 :f~..~ Po _1,
Work Description and Location
~c~
(Street Number, Hamlet,
Cross Street)
(a) Is construction lo~ated withih '75 feet of tidal wetlands? *Yes
*If yes, other-!own permits ,may be required.
No xxxx
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~1 ~~tk~-
.'. ". Signature of I dmt
,. . d/oJ,5"1 CiJ
, . Date
5) a) Attach plot plan showing location of proposed,e5f91vation 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 applicatiofl may 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............................. ..-..................... .oo.......
\.
Facility Installation.. ....... ......;.................
Backfill & Compaction........; ~ . . . . . .. .. . . . . . . . .. . .
Pavement Replacement..............................
9)
Under which authority is the application made:
Estimated Cost of Proposed Work: ,$
10)
11)
Remarks:
\'
D-39
Page 1 of 3
12) Insurance Coverage: (Attach copy) .
a) Insurance Company:
b) Policy it
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. IAdditional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ 01 0 oJ
No.
B. Excavations 18" in depth or: less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
"
~
~6
Additional
C. Excavations-..l8" in depth to 5' in depth:
0-100 I. f. =- $30. 00
.I.f. @ $0.30 =j
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 Town Clerk of the Tpwn of Southold to
issue a Highway Excavation Permit to: &-tnd//f'Y) 1./-",.//,,, ~
in accordance with -this application. ..
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
~
Jacobs
.1- ~ 7'- 00
Date
Received by the Town Clerk
c:z - c2 ~ - ou
Date
Permit Issued,. .,2/ ~'1' -f')r-,
Date
Permit No. -3 /
I
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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Request for lovJ
REQUEST FOR PERMIT
au-a!t,[]) Permit FEE' $
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Permit required to open!
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Permit Requested By:
3'2-
TD 130 0 Type of Road
Work Request # 1 ftit.- 03 0 Charge account #
... 0 Disbursement to be made out of petty cash
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rtlu,./PCLS
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o O.N. 0 Cent.
o W.S.
E.S.
Gas Service for
Return Permit To:
o New Business Department
o To be billed
o Underground Lines Department
o No fee
FC_114S.6-SS
DOper. Plan. & Cont. Center