HomeMy WebLinkAbout445 Marlene Dr
Date: 04/19/00
Transaction(s):
Permits
Check#: 828
Name:
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
828
Subtotal
$73.50
$73.50
Internal 10: 9192
Permit No:
File ~o..
.. . III.
70C
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New' York 11958
(516) 765'-3140
RECEIVED
, ,
APPLICATION/PERMIT FOR
d,S'13o' 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 excavat,ipn herein described.. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to make; necessary\inspections of the job site.
\:.
Print or Type
1) Brooklyn Union' Gas East
Name of Applicant
44S':East Main St, Patchogue, N,Y, 11772
Address
2)
Name of Owner of Premises
Address
3)
1"1'15 ~ 'f ') 6 (VI I'vz.l e '" <. U-t
Work Description and Location (Street
(VlATlI7\...<c:((
Number, Hamlet, Cross Street)
(a) Is construction los;ated within 75. feet of tidal wetlands? *Yes
*If yes, other-!own permits .may be required.
No XXXX
4) Builder's License No.
Plumber's License No.
Electrician's .License No.
Other. Trade's License No.
~~1 ~/Y\-~~-
.' ...... . Signature of I cant
Date
5) a) Attach plot plan showing location .of proposed,"e5<savation 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 applicatiotlmay not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
Tax Map: Section
, Block
, Lot
6)
7)
Starting Date:
C'ompletion Date
8) Work Schedule:
Phase
,
\,
Completion Date
Excavation. . . . . . . . . . . . . . . . . . ... . ~,; . . . . . . . .. . . . . . . . .
Facility Installation............. ~.;.................
Backfill & Compaction....... .;;;. . . .. . .. . . . . . . . .. . .
,
Pavement Replacement........:.,...................
Under which authority is the application made:
9)
10)
11)
Estimated Cost of Proposed Work: $
Remarks:
\
D-39
Page 1 of 3
1'2)
Insul"ance Coverage: (Attach copy)
.
Insurance Company:
Policy #
State whether policy
ment:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage. .
a)
b)
c)
\
of certification on file with the Highway Depart-
13) Security:
a) Surety Bond
tota I amount of $
or Certified Check
provided in the
b)
Maintenance Bond provided:
2 years or 3 years
Basic Application Fee....... .~25. 00'
excavations @ $20.00 = $ .2.0. (;J
A1.
applications and permits:
/Service Connections.
\114)
Fees for
~
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..."8" in depth to 5' in depth:
0-100 I. f. =. $30.00
C/.--
f:> . 1.f. @ $0. 30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I. f. @ $0. 50 = $
Additional
~
~13:>
Util ity Repai I" Excavations @$10. OQ = $
E.
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 SouthoJd to
issue a Highway Excavation Permit to:
in accordance with .this application.
EN DENT OF HIGHWAYS
SOUTHOLD, NEW YORK
Received by the Town Clerk
3/1I/8()
Date
Permit I ssued\ .
.3 //9/()O
'Date
. Permit No. Lj ~
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
RE'QUEST FOR STREET OPENING PERMIT
D STATE
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
. c
~ .s: 1..:-rHoL:P
MIS JOB. 5- . '. DATE
NO. Z +30-' 030 <I-
44s +- 4 7lJ IJ/J#Ll-Ji~. Il1k-rt:'fU.cl<
tuJ ~ MAJ'J ..,.- :;L 5Jc 5
FOREMAN
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DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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Perm it requ ired to open!
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Request for
It
Permit Requested By:
TO
REQUEST FOR PERMIT
<2~~l7::>
Permit FEE* $
.c/ 1 '.:}.Ce70
'/If.l: .e /S 6 -I ,4?~.'L
/1/! jJ'f >J 1/1) 7lL.e# ,:j7, 6-
/7"},1--/777;;c !.-
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o w.s,
E.S,
o a.N. 0 Cent.
Type of Road
Gas Service for
Work Request # ::-t~ [$ b Charge account #
* 0 Disbursement to be made out of petty cash
Return Permit To:
FC-1145.6-SS
o To be billed
o No fee
New Business Department
o Underground Lines Department
DOper, Plan. & Cant. Center