HomeMy WebLinkAbout2450 Wickham Ave
Date: 04/10/00
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Check#: 808
Brooklyn, Union Gas
444 East MainSt
Patchogue, N Y 11772
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
808
Subtotal
$65.00
$65.00
Internal 10: 8112
t"ermlt 1'10:
36'
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TOWN OF SOUTHOLD '
HIGHWAY ~EPARTMENT. E eel V E'
Peconlc,Lane <!6- n
Peconic; New ,York 11958 ft;!f
(516) 765'-3140 APR1' 200'
p. 0, !2><>'!- /7t>' .
APPLICATION/PERMIT FOR HIGHWAy ExcSltWllt1cb..WrNlDeREPAIR
File No:
.;J5L( gy -0 3:'"
.- ~.
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 make; necessaryjnspections of the job site.
\:.
Print or Type
1)
Brooklyn Union'Gas East
Name of Applicant
448',Easf Mdn St,
?atchogue. N,Y, 11772
Address
2)
Name of Owner of Premises
Address
':. .
3)~5V W\.c...~kA..... ~,
Work Description and Location (Stre~t
"Y'V'- A""ilLu.. L~
Number, Hamlet, Cross Street)
(a)
fs construction located withiil'75, feet of tidal wetlands? *Yes No XXXX
*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.
~tcl~/Y\-~-A-
,. '" Signature of I cant
': iJ 3/00
Date -
5) a) Attach plot plan showing location:o.f propos'~d<'e;(c;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 other necessary permits and licenses for this project.
c) Work covered by thisapplicatior1,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. . . . . . . . . . . . . . . . . . . . . .. ~ . . . . . . . . . . . . . . . . . .
. . \
Facility Installation. .......... .....;.................
Backfill & Compaction..........;...;...............
Pavement Replacement........' . .. . .. . . . . . . . . . . . . . . . .
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: '$
11) Remarks:
\
0-39
Page 1 of 3
."-', .-
12)
Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy II \
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
Applicatio~ Fee....... @
@ $20.00 = $ if (). c/'
vilLI)
Fees for applications and permits: Basic
A 1. LIService Connections, excavations
No.
A2. IAdditional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth Or less:
0-100 I.f. = $10.00
I.f. @ $0.10-$
Additional
C. Excavations.,,1'8" in depth to 5' in depth:
0-100 I. f. =, $30. 00
,I.f. @ $0.30 = $
f{p5~cY
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
1.f.@$0.50=$
Additional
E.
Utility Repair Excavations @$10.0Q = $
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:
in accordance with .this application.
SUPERINTENDENT OF H IGHWA YS
TOWN OF SOUTHOLD, NEW YORK
Raymond L. Jacobs
Date
Received by the Town Clerk
Date
Permit Issued,
Permit No.
Date
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without L18 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
0-39
Pa ge 2 of 3
~
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.
1.2)
13)
Security:
a) Surety Bond
total amount
or Certified Check
provided in the
Maintenance
of $
Bond
Al.
applications and permits:
~/Service Connections.
No.
A2. 1 Additional Excavations same service @ $10.00 = $
Basic
2 years or 3 years
Application Fee....... (;;~.~
@ $20. 00 ~ $ Ljo~ o2i-~
b)
provided:
\/14)
Fees for
excavations
No.
B. Excavations 18" in depth Or less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
C.
Additional
Excavations....l8" in depth to 5' in depth:
0-100 I. f. =. $30.00
.I.f. @ $0.30 =,$
~~s
DO
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:
in accordance with .this application.
SUPERINTENDENT OF HIGHWAYS
TOW F SOUTHOLD. NEW YORK
ll. <'C - <::'('1
,
Date
Received by the Town Clerk
</. 7 ' {Jd
Date
Permit Issued\
'-1- /0- ocJ
Date
Permit No. 3<f
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./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPAN /6/l5
REQUEST FOR STREET OPENING PERMIT
D D NASSAU D SUFFOLK fi71 (' -,-? / ......
STATE COUNTY COUNTY ~ -.jUJt.LIt-rIL/.J
MIS JOB DATE ;: /
NO. 2....c;y-w. - 03 <J ~ 1/~470
;e..td/h'VI -;-;)'. ))~s;-.. /300
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FOREMAN
II DEPARTMENT
eJ/<ifi GAS CONSTR. MAl NT. & SERVICES
N
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