HomeMy WebLinkAboutWickham Ave
File,No.
33
33
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic,. New York 11958
(516) 765"3140
P.O. f2,oY- /76
Permit No.
"w,'"
III:CEIVED 1;.-u-j
:;/J..J-- If' -rl -'1 If f:7
MAR 1 5 2IQ)
,M"fh~N/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
d 5d '1'-1- 63
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,
ordinimces 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; necessa ry ..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
sfsW\c~kA->-- /5ZJ' Cj" /VI, LL ~
(Street Number, Hamlet, Cross Street)
3)
4 ~ '( ~ 3 I 10 e \ \ h,)\ e Do:.
Work Description and Location
(a)
Is construction located withih 'is feet of tidal wetlands? *Yes
*If yes, other-Town 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 ~JV\-A__
. '. .... Signature of I cant
. '3;/3/ aJ
. Date
5) a) Attach plot plan showing location .of proposed-el<savation 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 tile 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:
\'
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
11'14)
Fees for applications and permits:
A 1. I /Service Connections
NO:""""
A2. IAdditional Excavations same service @ $10.00 = $
NO:""""
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ c;l.O. oJ
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
_ I.f. @ $0.30 =.$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
J.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.
* * *"
70ML 7 Y s-: c;;.J
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.
SUPERINTENDENT OF HIGHWAYS
TOWN 0 OUTHOLD. NEW YORK
00
Received by the Town Clerk a}S/bO
Date
Permit Issued\
Jj,s/oc:>
Date
Permit No. n.
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
Pa ge 2 of 3
........ -.~-. .......-..-
, ,-.-
,-,
RESIDENTL~L GAS REQUEST FORM .
KeySpan Gas. Corp. dfbfRfBrooklyn Union
\.,. _. - ~ ,I ~;.
;~ ',j B (.OO,'<Iy,,' '.
'\ UokHl", ,
I (l00) 0,\5'.200 I
.ll'STO~IER NA.\IE
J~. :. :_.' ,.(;.~:::-,.?::':!j;..:::.
".:R "ICE ADDRESS
1 Iud , w;/'iO
PLE.\SE r.;DICATE STAOo Of CO:---STl\U
PLE.\SE CHECJ.:
o Found2Lion 0 Fram~d 0 Ene
CO:---Tit.-> CTO?, P~:---E
.] s~ 135/
S/S 0 E/S 0 \VIS Of 1\.1,<::. (II/1m /II/.F
au REP PHO:---E
''.',,\JLr.-;o ADDRESS
r
S'< &>"
'.OCATlON
750 IT 0 r:/0 0 S/O ~E/O 0 \VIO
BuSL'\ESS REQUrR.E\lrr....TS
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o 7re5
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CUSTO~IER AU1HORJL,\ 110:'>
OF \lITTER LOCA 110:';
;; G:.5 Capacity R~quost R:q'Jir~dr" ". '
DNa
:: ?~5;or:21 Er.ycrlzL-;=~r_-:{R;;:q1... ....
u;';o
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WO,,-:-( REQUnu:"'l1::'>TS
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~:: i\'k~ Upgrzd;:........... ....... C:
~tr,.icc Rdoc;lt:Oil...... ......... C
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,
Exij:.ing Buildi:1g... DYES 0::0 I i
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':::WS?ACEh,t.ATi);G \./ 11'\ .J"" IGrid# 6-lr-G<GS'~
.<i:O \'/ WA I t.R tEA 1 J>.'G i 1,- I I Regulator Si,< .
'.::. W COO:<JNG .\,/ I . l , \ ]",.1-:0"5< ?r<S5C'"
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~.::. IV PROCESSt?\G I I I I DegreeD2Ys '!! _
~OIALS I \ I I Dam. Faewr i ( .....
L\lPORTA.:\T 1'\011CE TO CVSTO\lIERS REQUrRL\G J:\STALL.-\.TlOl\ OF A I'\LW BROOKLUYI\ UI'\1O:'> G,\S 1
;;.- Si;ning below, J l.::'I <,...j;:.-;:,;,; t~.H I~:;'\ t~c om"::. or 1--.1'.'C: :;,e j:CCr.liH;::'I cft:.: c..\';",:r 10 aUI!1cnz: l~' inSi..:!lb:icn of BroaUrn f~cililics at Ihis p;
.'_:-.::::r cr.ccrsuiid lob: if Broo~.:.I~.:l Ur.:o;i i;".s~l1s 3. n:w S::1S Fi;;c at my rCG'J:~:" ~,.; I Co n.;; l:S: I~C scrvic: :h:t I ~us: p.1)-' B;.x;~I~.n lJr.:o.-: [I;.r [he: ,;",:iil: ':
-,;'.:;Ibtion in :lCcor':lr.:c wi:~ :<,)-'S;::::1 G:a Corp's c."'v'a Brc-c;":l;..:\ U:l:c:\ G:!.; T.!~i!t LCJf No. 12:\. S:clicn 23. ~.<l ::'$ 2.;p:o...d cy I~.c Publi
~: ,--:.,:-,~i:;):O,l. 1l!.!>0 l.:,l~C::S~t,~ .:-.2; S:,;..;~l::i1 U..i.::n is r.C! fcspcn)i~k ref r";J\-i;:~ cr 1.:;,j)~1pin3 "n pii\.:;:: r:o;:..:r;:,'. I },J\.: r:.)j J;:~ :J~{';:': 10 III
':~.:,...:r:m:nlS ar.d cOil~it;cr,s c[:}.: r:"':lS~ ~;ce. ..
i C:-..::G 1..'S.'.G:':
CuSlomer Namo: (Pri.1t)__
rl1(!t\m~J' ,i!J'
Date: 03/04/03
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1096
Total Paid:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksvllle, NY 11801
1096
Subtotal
$345.00
$345.00
Internal 10: 71332
FILE No.71
ID:
FAX:
PAGE 2/ 4
File No.
TOWN OF SOUTHOLD
JDGRWAY DEl'AR~NT
peeonie Lane
Peeonle, NlIW York 11958
(631) 765-3140
APPLICATIONIPERMI1' FOR JDGRWAY EXCAVATION AND REPAIR
)
02-36
c2?Jrf
-
Permit No.
Ref.m00231S61
APPLICATION IS 1I1!U1IY _... ...lhe Soperi_..r W;b"ays .rdo. T_a .rs..t...w r.r Ibe ......r
.. EnaVOli.. PermlI panaa'" to Cllapter 13 .rlh. c...lt .rt... T_. "'500_11, S.<<oIt c..ot}, New Yorl<, .u odIer
.ppUco....lo.... .rell.......r .....1011... for tile tlCI....... btrd. deIcril>ed. The opplieu, oar- to eamply "it. .U
oppUcabl.lo..... .nIl........ .......u regglolla... ..d.. pmIIi....berlzed iDOpetl.n ......ICe DectIIOJ')' i........... orll"
jolt.....
Prl.t or TvDe
1) KEYSPAN ENERGY _ GAS CONSTR. DEPT. -175 Eo OLD collNTR.V RD. - mCKsvlLLEo NY 11101
N.... or ""pOca.. Add.....
1) Witkbam Avella'- Mattituek
N......rowaer.t~
.........
3) Wlekb.am Aventlle"- ODell a h'eneh to renalr a..1IS leak on Wk:kltam Avenue between Maia Road and
Middle 'Dn.d
Work DcacI1pdaD..d LoealIaD ($met N......... RaoIltt, C...... Street)
(.) 1I...iiInltlloa ....to4 wkblD 75 r...orti4ol ..,11_' <V.. No _X_
<Ir yet, ....... T_. per.... ....y b, reqairod.
4) BuUder'. LI_... No.
Plumber" License No.
EI..tric:iau'. LI_ 1'1..
Olber Tn
- '
"
pile 1
3
Date
S) a) Attach pia, plaD lhowiaC I_doa of proposed exeavatiOll tioalhlp III adj.inilIg premi.... or
pubUc....cdS or ar.... IIld C1vIDg . 4etaiIe4 deocrlpd.a of tayo.,or excavltloa.
b) Allacb aU other n......1')' permllS IIld licenses for llIis projeel.
0) Work covered by this application may aM cammcace before iso...... of a Wgbway Excavation Permit
by ,b. TaWIl Clerk.
6) Tu Map: Seetioa
7) Slamac Dale:
8) Work Sebedllle:
,Bloek
. Lot
Completion Date:
fJlJH Comoledon Dale
Ell:eavatioa ............. .... ........ ....... ........ ...... .,_. ..n.. ........ .........
'aciUcy IAltalIat:ioQ....... ......... '.n" .......... ...... ,. ...... ..nn. .......-
110<1</"'" '" C.llIp.<lioo........... ......... ................. ...... ....... .......
faveAlDpt RepIMClaellt....u.............. ........ .......... ..... .......... ....
g) Under wbiob aulllonl)' 10 llIe .pplkallon made:
10) EotImated COOlofl'rop00e4 Work: $
11) RellUlrks:
\).3g
Plg,lof3
. ,
FIL.E No.718 02/05 '03 12:12 ID:
FAX:
PAGE 3/ 4
T1OOZ31561
12) In!lUJ1lltce Covcra.e: (Attach Copy)
a) lnsU1'llllcc Company:
b) PGUcy#
c) S_ wbether pe>Ucy Gf certiflcatiGn on file wilb lbe Highway Department:
d) Coverage required extended IG me TG'Ml:
Bodily i!\iury and pr<>peItY damage: 53oo,000IS5oo,000 Bodily Injury, and 550,000 pre>perty damage.
13)~
a) Surety Bond Gr certified Check
Gf$
b) Maintenance Bonded provided: 2 years Gr
provided in the mUll amount
3 years
14) Fee< Ibrl\Wliealions and nennits: Bui. ADDlicatiGD Fee ................. $25.00
A I. ...1-JServicc Connecti<ms excavations @ $20.00 = $ 20.00
No.
A2. -,AdditiGiIaJ Ilxeavations same servi<o @ 510.00 ~ 5
No.
Ii. Bxcavations IS" in depth 0< less:
0-100 U = 510.00
\.f.@ 50.10 ~ S
Ac!ditiona\
C. Excavations IS" in dcplh to 5' in depth;
0-100 \.f. ~ $30.00 = $30.00
900 IJ. @ $0.30 = 5270.00
Additional
D. Bxcavations 5' in dcplh and over:
0-100 J.f. ~ 550.00
1.f.@50.50=5
AdditiGna\
B.
NG.
Utility Repair llxcavations@ 510.00 ~ 5
Repairs Wll&l service@ 55.00 ~ 5
Aclditie>nal
F. NGtice Ie> pllblic utilities pre>of musI be pre>vided and .-bed fA> this application prior fA> issuance Gf
pennit.
. . .
TOTAL COST 5345.00
AulhorizatiQll i& I\ettlly snouted '" 1ho Town Cletl< of1l1< TOWIl G(Southold 1D iss... a Highway \lxoavatian Permit to:
KEYSPAN F.NF.RGV DELlVERY.in __ with this applioatiQll.
PelerW%.
~/ t7 =?
~
. d--! J /03
Received by lbe TGwn Cleric
Permit Issued 01-/1 J /0 -3 Dalt Pennit NG. ;L;3,r
Hgu: Permit....i.... one (l)ycafll'om Date of_co. No _1O.tan wilhout48 he>urnoti.. ",the soporintendent ofllighwaY'.
Permit must be avail.hle for inspeotie>n.
D-39
Pale hl3
I PAYrorHE
I ORDER OF Town Of Southold .
'I ...... """"... F"">-F.....;, ..;.'00-____ , '-......00
' ", -----
Tawnof"",-, '--
OOf7S /
1
Ii
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g
6}
DOLlARs i
.
!
.
!
.
.
~
'00 ~ .
-'" .-.----- '.. II ~ 0 q S,I'O 1:,0, C ~, '- ill b " r. , _____________________ " j~
-...-.-.- . ." 'bOb 0 ,. __"'_~
-. .._~-------::::.-------------- '
"
'/ ...[ ".. ';~$; ,
ICEYSP.vi)~NtAGl' o~t., "
175!!Asr DLo COuI'lftry 1I11~Rl'
HICKsWI.L.E. Ny 11801'"'257
I
~
MEMO
T100231561
. "
. 0.. _________..
' ---------------.. .
" i
.1096 I
2124103 i
TI1e SAN/( OF New YOR/(
WESTBURY. NY 11580
.50-1063-214
FIL:E No ~M 02/05
ID:
FAX:
PAGE 2/ 4
FileNo.
TOWN OF SOUTHOLD
mGHWAV DEPARTMENT
peconic Lane
Peconlc, New Vark 11958
(631) 765-3140
~fLlCATIONIPERMIT FOR IDGHWAV EXCAV AnON AND REPAIR
C23Y
02?Jcf
(I)
Permit No.
Ref.#TI00131S61
APPLICATION IS HEIU:1IY IDa'" to III. SoperiAleadO...f lli;h".YS .rtb. T.". of50.t...14 fo. Ill. jUu.... of
a. Exavatioa Permll punoautto Cbapter 13 of lbo CocIe ort... To". of50.lboId, S.ll'oIk Co..I)', New York, ..4 olIler
app\iCablolaw<. onllon_.. ....lad... r.. Ill' ....valio. bud. d..erib04. Tbe appn..o.a;._ to oomply "itb .U
appllcabl........ onll.a...... 004.. a.4 ....Iado... .nd to penult ..I"'rIzod i.,peel." to makt .......ry i..peclIo...r tn.
job.;I..
Print orTvoe
1) KEVSPAN 'NERGY _ GAS CONSTR. DEPT. -175 Eo OLD COUNTRY RD. - mCKSVlLLEo NY 1 UOI
Na_.r ;.ppU..nt Addr...
1) Wickham Avenue. Mattituck
N.... of OWIlor orPreml...
~
3} WI~kh.m Aven.e.- ODell a UeJt~1t to renalr a.as leak. on Wt~kham Avenue between Main Road and
It'{lddle 'D".II
Work Doserlpdo. ..4 Looadou (Stnol Nu""". lWultt, C..... stroot)
(oj 11....stnI~.....t.d;.ilbl.75feet.rtiMl".d..dI? .V.. No_X_
'If)'el, othor T.". permits may bo rOIl........
4) Build"".. L....... No.
Electrldaa'. U- No.
Plulllber'. L\Cellse No.
- \
'f
plic t
3
nate
S) a) Anaell plol p\all sbowiu& locadou 0( prGp6,ed excavatioo tioaJblp to adjoilliug premi.... or
pubUe lIreolS or ....... 1114 &lvIDl a detailed deacriptioo 0( layoulof neavadon.
b) Attaelt aU od1"" 0_1')' permlta and Ii_set for tltis project.
~) Work _e.-ed by tltls applioadan may oot o:ommeocc: before Isaoaacc: of alllgbway Excavation Permit
by tlte ToWll Clerk.
Ii) Tax Map, s.euon
7) S1ardog Date:
B) Work SdIe4u1o:
. Block
. Lot
compleUo. Dato:
f.bU Comoledaft Date
kcavatloa ...n.................... ..................................... ...........
F.ciU'1ll1lta1latio................. ...... ...n.......... ...... .......... .......-
DIM.... CaQlP.c:tioa........... ........ ................ ............... .h....
Pav~ ~IIC1AWDt..,;n...n...............................................
9) Upd.r wltl'" autltGr1ry Is tlte appl\ealioo made:
10) Elldmatod Ceill offrop0ae4 Work: $
11) Remarila:
\).39
Pig. lor 3
FILE No.\18 02/05 '03 12:12
ID:
FAX:
PAGE 3/ 4
TI00231S61
12) In""""ce ('""",mee: (Attach Copy)
a) Insurance Company:
b) PoUoy#
c) S_ wllcther policy of certification on file with Ibe Highway Department:
d) CoVCtllge required exrended to the ToW\\:
Bodily injury and property damage: $300,000/$500,000 Bodily il\jury, and $50,000 property damage.
13)~
a) Surety Bond or Corlified Cbbck
ois
b) Main(alanCe Bonded provided: 2 years or
provided in the tolal amount
3 years
14) pees for "I'pHoations and permiTS: Buie ADplicatiOD Fee ................. $25.00
A I. ...1-IService Connections excavations @ $20.00 = $ 20.00
No.
A2. _/Addilional Excavations same service@$IO.oo=S
No.
B. Excavations I goo i. depth or less:
{J..loo ~f. = 510.00
I.r. @$0.10=$
Ad4itionai
C. Excavations 18" in depth to 5' in depth;
{J..!oo I.f. = 530.00 = $30.00
900 1.f. @ $0.30 ~ 5270.00
Ad4itiOllA!
D. BxcavaliOllS 5' in depth and over.
{J..!oo I.f. = 550.00
l.f. @ $0.50 = 5
Additional
B.
No.
Utility Rqlalr Excavations @ $10.00 = S
Repairs llOIllll service @ $5.00 = S
Additional
F. Notice to pllbHc utilitieS praofmusl be provided and _lied to thiS application prior to issuance of
permit.
. . .
TOTAL COST 5345.00
AulhorizatiQII 1& hereby _led 10 dlI To... Clerk of 1110 Town of Soulhold 10 issuc a Hishway Excavation Permit 10:
KEYSPAN Il.NERGV DELIVERY,. ~w1tll this appl_.
Received by tbe Town Cleric ~/r "jC3
permit 1ssuod ,;1./1 J /0 .3 Ca,.
S~,. TOFHIG~
TO! lOFSO ZiV:-YO .
~/;~k~
~
Permit No. ;2.. ~ r
NlllR: pllI'II1lt....ireo 01\0 (I) yt# tram Dale or_ceo No worl< 10 SWl w1lhout 48 hour .olict 10 tho supmnlOftden, of HighwaY'.
Permit must be avail.hie for inspoetion.
Pa.o Z oU
11-39
13/02 '03 THl' 12:02 FAX 516 705 6145
SOUTHOLD CLERK
I4J 001
*********************
**. TX REPORT .*.
*********************
TRANSMISSION OK
TX/RX NO
CONNECTION TEL
CONNECTION ID
ST, TIME
USAGE T
PGS. SENT
RESULT
4239
151054544 74
13/02 12:01
00'55
2
OK
FILE NO.71~l1 ID:
Permit No. a 3 f
02?JC
FRX:
PAGE 2/ 4
-
FileNo.
TOWN OF SOUTBOLD
IUGBWAVDEPARTMENT
l'econieL8Illl
pecllDle, New York 11!J58
(631) 765-3140
APpLICATIONIPERMrt' FOR BlGBWAY J;:XCAV"TION AND REPAIR.
1>~m00:l31S6t
.u>PUC4T10N IS JfEIlI:8Y ...40 '" III. SoIpori.....-. of IIicb".Y' arth. To". or 5oolbold for dI. -.... or
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applkable la~ Qnll..DUS Dr np1adua, for the aovaliaa buell' dtsu:n'bc:d. TIle' applicut ql'eul Co .'Dipl)' with .u
appU-=alrlo Ia..-s" ordloaDC:tlIt code:s lII.d nglllado~ "..4 tQ ~i' aatborlzed iJll5pCClAnl 1D IMIce ..et:CU&JT illspecnonl ufttIe
Job.ilt-
PriDt or TVI)~
1) KEVSPAN KNERGY _ G4S CONSTR. DEn, -17S l1.. OLD COUNTRY RD. - mcl'sVn..LE. NY 11801
N....afAppllea.. Ad_
1) Wickham AY!:IIHe. Mattituck
Nom..r awael'.t l'TeroI...
~
3) Wickham Aft'o\1e,- obe1l a n-encb to reml.. a rid leak. on Wickham Avenne bdwcen MaiD Rmld and
!>flddlo RolUl
Work D...rlpdo. ..4 Ll>roIlaD ~ N."""".1IomI<<. C...... S.....)
(0) Is "'oiil7u<llaalooa1'o4 ..,dlla 7S f'" oCli4II wellud<'1 .V. N. _X_
"Irl"', .Ill... TaW. potaall> IIIOY be roqorirul.
4) Builder't Uce... 1'1 ~
EleoIriw's 1.1_ No.
Plumber's1.lcetifll'lll-
-
"
plie t
3
Date
S} a} AtIlleh pill'! pw. .....wiD& locallo. of ,,"pOle<! ex..valio. lio.shlp ,. adloiaiDg p~... or
pubUc streetS or ......... ..d clll\all . detailed desrripllo. .f1.yoal of ex.....ti...
b) Attaeh all other n_ry permits IlIId Ii_ for this pr.j"~
0) Wort<. .ovend by Ihb applicallon may U'I ,,"mme... bero.. iml...., of" Bigbway Es""..II." Permit
by lb. Town ct..k.
6) Tax MaP' ~iao
. Black
. Lot
"T\ ~.artiD.p. Date:
CamplclklD Dale;
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765-3140
L
. "
Permit No. /{)
File No. It?
.~,.,,,,,,,,,,,''''(''';'~id. ...,...J,........'..;. ..4/.4"._".,..,~..-...,........,..
.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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. rhe applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to ma,ke necessary inspections of the job site.
Print or Type
1) Richard G. Relyea
Name of Applicant
P.O. Box 372 Laurel, N.Y. 11948
Address
2) Ali Agarabi Wickham Ave.
Name of Owner of Premises
Mattit,llrk. N.Y llq'i?
Address
3) Wickham Ave M;,ttituck [Farmer]
Work Description and Location [Street Number, Hamlet, Cross Street)
[a) Is construction located within 75 feet of tidal wetlands? "Yes
"If yes, other Town permits may be required.
No x
4) Builder's License No.
Plumber's License No.
Electrician's License No. 2148E
Other Trade's License No.
r-~",E~
03-28-90
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.
6)
7)
Tax Map: Section
114
Block 3
,Lot 1
Starting Date: A.S.A.P.
Completion Date 04-30-90
8) Work Schedule:
Phase
Excavation........................................ .
Facility Installation.................................
Backfill & Compaction..............................
Pavement Replacement..............................
Completion Date
~
9) Under which authority is the application made:
10)
11)
Estimated Cost of Proposed Work: $
800.00
Remarks:
D-39
Page 1 of 3
.
.
112) Insurance Coverage: (Attach copy)
a)
b)
c)
Insurance Company:
Policy #
State whether policy of
ment: no
d) Coverage required extended to the Town:
Bodily injury and property damage: $300.000/$500.000 Bodily Injury.
and $50.000 property damage.
Roy Reeve Ins / Commercial Union
CJ LB 14412
certification on file with the Highway Depart-
13) Security:
a) Surety Bond 11/4- or Cer~ified Chack ifill
total amount of $
f)rov:d~d in !~::
)./4
2 years or
# 3 years
b) Maintenance Bond provided:
14) Fees for applications and permits: Basic Application Fee........ $25. 00
AI. /Service Connections excavations @ $20.00 = $
~
A2. /Additional Excavations same service @ $10.00 = $
~
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I. f. @ $0.10 - $
Additional
C. Excavations 18" 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 Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: ~i:!hARL. g. tf'e.t,vel'1
in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN OF UTHOLD. NEW YORK
/2'.
aymond L. Jobs
"3 ~.;:1 '7 - 9c:r
Date
Received by the Town Clerk
~/dltJ/~~
, Date
Permit Issued
~4<<~t?
Da e
Permit No.
/0
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
.
.
.
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
I nspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
I B - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under 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
.
.
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RAYMOND L. JACOBS
Superintendent
DATE:
TO:
CASE NUMBER:
.
Highway Department
Town of Southold
Peconic Lane
Peconic. N.Y. 11958
.
This is to notify you that New York Telephone Company
and Long Island Lighting Company have been notified in
the Town of Southold.
respect to the application for an Excavation Permit in
Ad
Signature of the appli nt
Tel. 765.3140
.734.5211