HomeMy WebLinkAbout2000 Westphalia Rd
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #37
Received $ 45.00 for 1 - Permits on 04/03/2000.
This receipt covers the following PermitlSticker(s):
It is always our pleasure to serve you.
By:
I
I~H~ft-t
./
{?Iv 7f 797
at
(time of day)
Permit NO'-91-
File No. '11
TOWN OF SbUTHOLD
HIGHWAY DEPARTMENT
Peconic,'Lane
Peconic;, New York 11958
(516) 765'"3140
P.o. t2>o~ /75'
dG31')-o]
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 excavatipn herein described. The applicant agrees
to comply with all applicable laws, ordina,n<:es, codes and regulations, and to permit
authorized inspectors to m1ake; necessa ry:,/nspections of the job site.
Print or Type
1) Brooklyn Union Gas East
Name of Applicant
448 :East Mai,n ~, t. Pat ho~ N y 11772
" c' "ue, .'.
Address
2)
Name of Owner of Premises
Address
3)
e.-
and
t4-.-, AnI1\...( <.. (c..
Cross Street),
(a) (s construction lopted within '75, feet of tidal wetlands? *Yes_No xxxx
*If yes, otherTown permits :may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other, Trade's License No.
~j" ~~~-
'..: '. Signature of I cant
" 3 JJ-K'I 0\)
, . Date '-
5) a) Attach plot plan showing location of proposed.e5C:<::avation and relationship to
adjoining premises or public' str'e,ets or areas, and' giving a detailed descrip-
tion of layout of excavation. ..
b) Attach all otner necessary perrnits and licenses for this project.
c) Work covered by this applicatioh.may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
.'
6)
7)
Tax Map: Section
Block
, Lot
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:
Estimated Cost of Proposed Work: ,"$'
10)
11)
Remarks:
"
0-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
~SJr,J.db)
c)
P~icy # \
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
11'14)
Fees for applications and permits:
A 1. I /Service Connections.
~
A2. /Additional Excavations same service @ $10.00 = $
2 years or 3 years
Basic Applicatio~ Fee.... r.:.$25. o~
excavations @ $20.00 = $ ~O. ~
~
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 iss.uance of permit.
* * '*
J7) 7'rr I
"1:5-- o: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 OF SOUTHOLD, NEW YORK
Raymond L. Jacobs
Date
Received by the Town Clerk
1- 3 -{} 0
Date
Permit
Issued\ ~ -3 - ()cJ
Date
Permit No.
37
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.
0-39
Page 2 of 3
,
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
J
or"
~
:l:.?
<::. CI'
I""u\,
KEYSPANj'bAS
REQUEST FOR STREET OPENING PERMIT
O SUFFOLK ri71
COUNTY ~
25312 -e:.d {)
ZDfrJ LJ~s/. 'M /"/; ~ If/)
;J~w &-/is S'kL
FOREMAN
o STATE
NASSAU
COUNTY
MIS JOB
NO.
o
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
iJsi (C
LLOO
t'.s.1Z.
/.;j f:.S17J J A LA
J...tfo'+
<r x. <I c-1
'I
.
DATE OF
OPENING t:f .;2000
DIVISIO~;1 11
S:'u-l+o LK.. ILL670,J 3
DATE
N
Rn 1Ft)