HomeMy WebLinkAbout1345 Sigsbee Rd
Date: 03/20/00
Transaction(s):
1 Permits
Check#: 783
Name:
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
Clerk 10: L YNDAB
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
783
Subtotal
$45.00
$45.00
Internal 10: 4983
Permit No. '- "1,f
File No. ....3'1-
I
TOWN OF SOUTHOLD .-
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic, New York 11958
(516) 765~3140
PO. (2,oY- ,7e,
,J RECEIVED
4.5. 0 0
MAR 2 0 2DOO
SouthoklTnwn&LICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
;)5;)00-0J
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, ordinances, codes and regulations, and to permit
authorized inspectors to mlake: necessary ..inspections of the job site.
Print or Type
1) 8Qoo~\.'r,"", -Vr-' 0...... G-A-1
Name of Applicant
'i't f . E. /I11t,~ s r - PI} Tel,; r'~
Address v
1"7
2)
Name of Owner of Premises
Address
3)
t<tJ
(a) Is construction lo!=ated within 75. feet of tidal wetlands? *Yes_No
*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.
/Yh'f.1;.1 I~ /' ~-
Ignature of p i~t
3}n /tP
Date
5) a) Attach plot plan showing location of proposed. e~'cavation and relationship to
adjoining premises or public'streets or areas, and giving a detailed descrip-
tion of layo.u.t 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.
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:
il) Surety Bond
tota I 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. --L.-/Service Connections
No.
A2. IAdditional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ~O' ()J
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
.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 = $
.~":Jt{).u
attached to
Additional
_r'-
F.
Notice to public utilities proof must be provided and
this application prior to issuance of permit.
* **'
Authorization is hereby granted to the Town Clerk of the Town
issue a Highway Excavation Permit to: (FSra-o K/4p1U (J" "blll
in accordance with.this application.
of Southold to
G"tS
ENDENT OF HIGHWAYS
SOUTHOLD, NEW YORK
Raymond
;3 ~ CO - Oc
Date
Permit Issued\
lJ(,;l.oIDc)
Datel
Permit No.
~Q~
i2Lj
Received by the Town Clerk
~ifol6D
Dat
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.
Page 2 of 3
D-39
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
IN SPECTOR'S
RECORD
I nspection Date
Findings (use code)
1st
2nd
3rd
4th
-'
/"
D-39
REMARKS
CODE
Applicant Notified
(To Permit Clerk)
IB - 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
\
Page 3 of 3
.-.. ~-----_.__...~--~.,._-- -.--. ._____________.._...._H___ - ----,,-
'i'i> Brooklyn RESIDENTIAL GAS RI':QUJ~ST FORM
.. Union KeySpan Gas Corp. d/b/a/ J3,'ooldyn Union
, (HOm O^-~.2001 /
CLlSTQMER NAME. . K:K f:U. (/if.. GA L6A&-ftrL- IlU Jlr:~ci1 r IJJ/,EI~~~m C
. . ......,2- ~ 1'.';'7- .. ~ J<.t.c
SI:K VICE. ADDRESS 134<') S,'cP'gz.'Z.. &(, TOWNM ::rrt-- ~c. Zoll'
, k[ I I
~'..\II.1NG ADDIU;SS 1I0~m "liON'; I'LEAS'; ,NDlCAn: STAGE OF CONSTIlUCTION
I'LEASE CllECK
CQ:-ITIlACTOIl NAME 1 CONTRACTOR I"'ONE IlUS,NESS l'1I0NI: 0 FOllnd.1tion 0 Framed o Enelosed
B<;.L€ It;Lf o NIS . 0 SlS o ElS ~ WIS OF e:::;:Z5~f' 7Z, -/ "d-J'L --;:"1 tJ]s;7 h,A-# )
LOCATION / 6S {) FH 0 N/O )6...S/O o ElO 0 WIO J'1141,.l /J2,
DUSINESS REQUIREMENTS (/l CUSTOMER A UTlIORlZA TION
c:; OF METER LOCATION
Is Gas Cal.1city Request Required7... ... oNo Yes "
0 l"-
Is Regional Eng/Engineering Req? ...... oNo 0 Yes ti.s~ If t345
Are exccSS Atlachment Chargcs Rcquired? oNo 0 Yes ~ *'
.... - ~
WORK REQUIREMENTS
No Work Requircd........ 0 Ncw Gas Main wlService .....0 ~ /1"-
Upgrade Meter... .......... 0 Service Upgrade...... .... ........ 0
New Meter..................o Service Relocation...... ......... 0
RiserlHeader Work... ..... 0 Meter Relocalion...... ....... .... 0
New Gas Service Lalcral 0 Existing Building... DYES oNO 5: &sAu... IL u
"
Street ~
SITE INFORMATION Vi
0 Macad.1m oNone o Cesspool COMMENTS
0 Concrcle oTree oOiltank .
0 D irtlSod o Slcep Ineline o Sprinklcr LD .0. 'fF t2 5 .:Lfo~ tJ30
0 DUG Electric 0
0 Customer to remove/cut back bush
0 Customer 10 install protcction posts
o Customer to install p3k ' .
Len~lh q 0 ' & ('f
New Service Diam J- Pres~
Mcter 0 Inside I ~011l o ..Rcmot~
Existing Main Diam L Mtl ( Pres ~c
,New Main Diam - Length _ Pres -
Work Order 1/ Meter Order 1/ ,
One Call Case 1/
GAS USE CHECK USAGE BTU INPUT/I.lIt THERMSIYR Square Foot:l!:e lIe:lted Sllace
Large Meier :..Type Size
EXISTING LOAD Aecounl II
NEW SPACE HEATING V Grid II
NEW WATER HEATING Regulator Si"l.c
NEW COOKING In-House Pressure
NEW DRYING New fulle Code
NEW PROCESSING De!:ree Days I If I
TOTALS DOIll. F:letor
IMPOltTANT NOTICE TO CUSTOMEHS llEQUlIUNG INSTALLATION OF ^ NEW BllOOKLUYN UNION GAS PII'E
lIy Sigl\il\g hcll\w. I .111 wlifying ,1..1 I "III ,he I\wner I\r h.ve Ihe pcrllli";1\1\ of ,he owner '1\ .nlhor;,e Ihe in,I.II",iol\ of 1I,00kly" f.eili,ie, .. thi, prope,'y.
fo,.he, I\,,,tml.,,d th., irll,ooklYI\ Ul\iol\ i",'all, a new I;a' pipe allllY "'1ne,'. and' do I'l'l n,e ,he ,erviee ,I",' I n"',"I"'y 1J,00klyn Unin" for Ihe e",i,e ",,' of"
il\""II.,il\l\ i" .eeord.nee wilh KeySp'l\ Ga, Cu,p', d/h/a IlrooklYI\ Union Ga, T,,,ill'. Lear Nn. 12^. Secli,... 21J. -1.,1 '" "1'1"nvcrl hy ,he l'l\hlie Se,vi-
COlllmission. I Rlso IIndcrslnnd Ihnt Brooklyn Union is 1101 responsible ror rcp:lvillg or l:uulsc:Jping 011 privfllc properly, I h;avc (c;ad nnd agree 10 lhe Geller
Requirements 8nt] conditions or the revenc side.
Customer Name: (print) Customer Sig: Dale
Custol11crlDU Agreement Date DIU Rer Si&: