HomeMy WebLinkAbout300 Soundview Ave Ext
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #35
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
Received $ 45.00 for 1 - Permits on 04/03/2000.
This receipt covers the following Permit/Sticker(s):
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It is always our pleasure to serve you.
By:
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Permit NO'-...as:
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file No. J
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic,'Lane
Peconic" New York 11958
(516) 76SC. 3140
P.o. ~C!~ /71:>
<953Q5-03
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 excavati()n herein described, The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to m1ake; necessarY\',nspections 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)
. I e J .'
4 ..,.. Lf e.J1 MI e
Work Description and
O,J 7\.--0 Sl<; Sd.....~J) 11 ,eo.-J C' 'i-"" I &-cd ,
Location (Street Number. Hamlet, Cross Street)
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(a) 1's construction lo~ated within 75 feet of tidal wetlands? *Yes _ No XXXX
*If yes, other-fown permits ,may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
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,. " Signature of I cant
; 3k/6>
Date
5) a) Attach plot plan showing location of proposed.'e~9vation 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 applicatiohmay 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
9)
10)
11)
Excavation............. .. .....' eo ...~\~.. ...............
Facility Installation . . . . . . . . . . . .. . . ; . . . . . . . . . . . . . . . . .
Backfill & Compaction......... ~....................
Pavement Replacement........:.,...................
Under which authority is the application made:
Estimated Cost of Proposed Work: ,'$
Remarks:
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D-39
Page 1 of 3
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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
tota I amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
3 years
A1.
applications and permits:
~/Service Connections.
No.
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ dO. oJ
\114)
Fees for
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 = $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * "*"
"rtFYt (
y~ em
Authorization is hereby granted to the
issue a Highway Excavation Permit to:
in accordance with .this application.
Town Clerk of the Town of Southold to
-
NDENT OF HIGHWAYS
OUTHOLD. NEW YORK
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Received by the Town Clerk
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Date
Permit
Issued, "-l .3 - Qc!
Date
Permit No.
.3S
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
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
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KEYSPAN/CA.J'
REQUEST FOR STREET OPENING PERMIT
o STATE
o
NASSAU
COUNTY
O SUFFOLK
COUNTY
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DATE , /
3J,UNMO
MIS JOB
NO. 25"315 'o3v
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DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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