HomeMy WebLinkAbout1830 Pike St
.
Date: 04/10/00
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Check#: 811
Brooklyn, Union Gas
444 East Main St
Patchogue. N Y 11772
Town Of South old
P.O Box 1179
Southold. NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
811
Subtotal
$45.00
$45.00
Internal 10: 8121
Fik No.
tjO
10
TOWN OF SbUTHOLD
HIGHWAY DEPARTMENT,
Peconic,'Lane
Peconic;, New York 11958
(516) 71>5'"3140
PO. !2>e>'t- /75'
flEeEIVE
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APR 7~'
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c;) ~55-'-I S- - Q ]
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
;tOUthotd , own u..'
\:.
1) Brooklyn Union Gas East
Name of Applicant
448',:',East Main St. l' t h N Y 11772
,a c 6~ue, . .. .
Address
2)
Name of Owner of Premises
Address
3)
ST -
and Location
A-TTl TZA c Ie
(Stre~t, Number, Hamlet, Cross Street)
(a)
fs construction located withih '75 feet of tidal wetlands? *Ves No xxxx
, ,.'
*If yes, otherTown permits ,may be required.' -
4) Builder's License No.
Plumber's License No.
Electrician's License No.
" : Other Trade's License No.
~~l~;Y'-O--A-
", ' Signature of I dmt
, V/)I ~
Date
- .
5) a) Attach plot plan showing location ,of proposed<'e5c!=.avation and relationship to
adjoining premises or public'str'e,ets or areas, and giving a detailed descrip-
tion of layout of excavation. "
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this applicatiol1may not commence before issuance of a
Highway Excavation Permitby'th,e Town Clerk.
Tax Map: Section
, Block
,- , Lot
6)
7)
Starting Date:
Completion Date
8) Work Schedule:
Phase >\ Completion Date
Excavation. . . . . . . . . . . . . . . . . . . .' 0,.. ~ . . . . . . . . . . . . . . . . . .
'. \
Facility Installation .... ., .... .....;.... .............
Backfill & Compaction....... .:~ . . .. . . . .. . . . . . . . .. ..
Pavement Replacement........:.,...................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: ,$
11)
Remarks:
\
0-39
Page 1 of 3
,,' .._ ,. """"'"-_,_ ._. .-..,-0-
r'2} 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 amoun t of $
b} Maintenance Bond provided:
or Certified Check
provided in the
2 years or 3 years
Application Fee....... Q
, 7 ~
@ $20.00 = $ 0 (:)
v'14)
Fees for applications and permits: Basic
A 1. /Service Connections. excavations
No.-
A2. /Additional 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...l8" in depth to 5' in depth:
0-100 I. f. =. $30.00
,I.f. @ $0.30 =.$
~/ s- ce;L
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 = $
-
Additional
E.
Uti! ity Repai rExcavations @$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~ SOUTHOLD:, NEW YORK
4/; /} ~~~.. ~ .
<--4:/ v' --c;..:...-r -- ' ---
.~nd L. f! bs ..
.,/.- (I': -Cy)
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 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
0-39
Pa ge 2 of 3
1-2) 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 amoun t of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or 3 years
Applicatio~ Fee...... ~
@ $20.00 = $ dO- u--
\114)
Fees for applications and permits: Basic
A 1. I /Service Connections. excavations
~
A2. /Additional 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...l"8" 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
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.
* * *.
TV )'Y1-(
VS-: cJ
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
Date
Permit I ssued\
Permit No.
Date
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
.
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
~
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k:
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D STATE
KEYSPAN /6-IlS
REQUEST FOR STREET OPENING PERMIT
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
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~~JOB 2554 - 030
5'-50 I /(2: :Sr'
dctJ GAS S'JCL..-
FOREMAN
~v;tI ~~t 12
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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