HomeMy WebLinkAboutSoundview Ave
Date: 04/19/00
Transaction(s):
1 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
$45.00
$45.00
InternallD: 9193
Fne No.
'73
RECEIVED
u permit NO;
TOWN OF SbUTHOLD
H IGHWA Y DEPARTMENT
Peconic.'Lane
Peconic, New.York 11958
APPLICATION /PERMIT FOR
.....51 'I ?
d \.CO' -OJ.
APPLICATION IS HEREBY made to. the Superintendent of Highways of the Town
of Southold for the issuance of an Excmhltion 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 excavation herein described. The applicant agrees
to comply with all applicable laws, ordinan'ces, codes and regulations, and to permit
authorized inspectors to make; necessarY~,i.nspections of the job site.
Print or Type
1) Brooklyn Union Gas East
Name of Applicant
448 .East' Ma:l.n St, Patcho!,\ue, N,Y, 11772
Address
2)
Name of Owner of Premises
Address
3) t3 d I h.J~ f) ,J IL.: s, / S StJ '^ ~J . c>.J /J.-e.. .-J /). n
Work Description and Location (Stre7t Number, Hamlet, Cross
.iJ ;4vr" ,.,.. ~.--.::(
Sl(reet)
(a)
Is construction located withih'75 feet of tidal wetlands? *Yes
.- .
*If yes, other-Iown 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~/V\-~-A-
. ..... '. Signature of I cant
Y-:jJ (I"
Date
5) a) Attach plot plan showing location ,of proposed.'ei<:Savation and relationship to
adjoinfng premises or publicstt'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 application. may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
Tax Map: Sectfon
Block
,- , Lot
6)
7)
Starting Date:
Completion Date
8) Work Schedule:
\,
Excavation. . . . . . . . . . . . . . . . . . . .'. .' ~ . . . . . . . . . . . . . . . . . .
. \.
Phase
Completion Date
Facility Installation. ......... ~.....:................
Backfill & Compaction........ .......... ......... ....
Pavement Replacement..........,...................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: '$
11) Rema rks:
\
D-39
Page 1 of 3
12) Insurance Cover~: (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
Application Fee...~... ~_ .001
- ~,,:>~
@ $20.00 = $ dO &>-
/14)
Fees for applications and permits: Basic
A 1. ~/Service Connections _ excavations
No.
A2. I 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--1'8" 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
I.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.
* * *
~
T7J /Yrl V..)-' OJ
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
y ~ I t( ~ 0,,)
Date
Permit I ssued\
4/ It q foe;
.Da te t
1//1-7/00
I Date
Received by the Town Clerk
Permit No.
L/3
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
f
KEYSPAN/&",1S
REQUEST FOR STREET OPENING PERMIT
"B f. L( ,hL-C.
D NASSAU D SUFFOLK
COUNTY COUNTY
MIS JOB DATE
NO. C:<5t.1/- ()30 <I, '3 ;7.000
""-< -rue s/s 01 s;,,,,,,,i)V/ft.J fWi: (i-! 111-1: Ih~,?f~#'r 1'11I4y
u-;r s 5uc L
FOREMAN
D STATE
[RJ
5"0 ,...:iHo L. u
-
fvJ
S":.-rlul2-
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
N
61n5 ;fa
lis [ #
Zo2.50
GA.;?lj!. /07-/3 -77<).5(</.)
50 luiD VI"L J AvL -t'
2" S1L g c.{ (K<f. ' cd.
, 15"0 '~ ~T
rj
'"
Date: 04/19/00
Transaction(s):
1 Permits
Check#: 828
Name:
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
828
Subtotal
$45.00
$45.00
IntemallD: 9196
YermJt NO.
~'~ No.
TOWN OF SbUTHOLD
H IGHWA Y DEPARTMENT
Peconic,Lane
Peconic, New York 11958 APR 1 7, "',,'
(516) 765'-3140 ~ 11 ..- ".1
P. 00 /2>0 Y- I 75 ' t' 7.,"'>
, ,otlt~n,;r T ""'" CI",""
APPLICATION/PERMIT FOR HIGHWAy EXCAVATION AND REPAIR
RECEIVED'
is;
"0
,,'
dS (.,,':JCJ. OJ
APPLICATION IS HEREBY made to the Superintendent of l:Iighways 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,
ordinimces or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinan'ces, codes and regulations, and to permit
authorized inspectors to mlake: necessary..inspections of the job site.
Print or Type
1) Brooklyn Union'Gas East
Name of Applicant
448' ,East Main St. J'atchogue. N.Y. 11772
Address
2)
Address
,.-J ILe /~,M"C";-JI
Hamlet, Cfoss Street)
Name of Owner of Premises
3) (3" /l1",)le /)..J O-c S) S. Sa u. :..]J (j,el-.J
Work Description and Location, (Street Number,
(a) fs construction 10j:ated within 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.
~~1 ~/V\-~~-
. .,. . Signature of I dmt
. y.;] (}J
Date
5) a) Attach plot plan showing location ,of proposed,'e5<savation and relationship to
adjoinIng premises or public' streets 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
Excavation...................... :\:.................
Facility Installation............. ~...................
Backfill & Compaction....... .;~....................
Pavement Replacement....... .~,.,' . . . . . . . . . . . . . . . . . . .
9)
10)
11)
Under which authority is the application made:
Estimated Cost of Proposed Work: "$
Remarks:
"
0-39
Page 1 of 3
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 or Certified Check provided in the
tota I amount of $
b) Maintenance Bond provided: 2 years or 3 years
1114) Fees for applications and permits: Basic Application Fee......~)
A 1. -L/Service Connections. excavations @ $20.00 = $ ';;;0 0-'
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...1'8" 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
I.f. @ $0.50 = $
Additional
E.
Utility Repair Excavations @$lO.OQ = $
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.
TD~(
JI Y<; (}J )
* * "*"
~-----
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in uccordunce with .this application.
SUPERINTENDENT OF HIGHWAYS
TOWN F SOUTHOLO, NEW YORK
L( -/ tf -00
Oate
Received by the Town Clerk
Permit Issued, 'I/Ir/o()
Oat
/-j )7~O
Oute
Permit No.
Ljr
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
KEYSPAN/&AS
REQUEST FOR STREET OPENING PERMIT
D STATE
D
D SUFFOLK rFl
COUNTY ~
'PI/Iff<)
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
!1,DtJulhi
I-Is'i 4f 2 Z~ 1.5
6ii D p;. 167 <1..-1 - <1417(3,)
r
/ ()O I "!.
~oUNb()"LW
l'YrL_
N
/WE-
A
~
~
~
--
~
I
.
Date: 05/31/02
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Check#: 4667/75
J., & M. Long Island Inc.
POBox 2507
Southampton, NY 11969
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
o
Subtotal
$55.00
$55.00
Internal 10: 55995
10)
11)
D-39
Permit NO.1%
File No. / r
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(~) 765-3140
"'Dr
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 excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to mlake" necessary inspections of the job site.
Print or Type
1)
<-
/10 !J6v
li,n. kY /169
::J~ 11 A (;
Name of Applica
2) Wdl/</ M, jv/qf10 \ '16-,~CJ ).J/~ Ii /J"Vfidf A/V
Name of Owner of Premises / 'Address
3) ,~,;. ,<,<1:.1 c-",J.'r 6/{j /;D3-:; .s()~,.,L!<:~ Ai/c fc,J/uW 'J /J(j()fJ /c/
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes_No 'X
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No. J f <.; / IZ P
Electrician's License No.
Other Trade's License No.
Jvm~ Ie. 2~
Signatur pplicant
,rid} Od-.
I Date
5) a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises or public streets 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 application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
6)
7)
Tax Map: Section /000 -,,-'I
Block OS ,Lot (If,. ,
Completion Date !; h ",/0 ).
/
Starting Date:
,( I;), r./O ;)
, ,
8) Work Schedule:
Phase Completion Date
Excavation......................................... u/or;:' /.~ td
Facility Installation................................. D"m /I1e,,, e 4 ;1/~
Backfill & Compaction.............................. ;:.> ~'/ /;2') ,,,-
Pavement Replacement.............................. _, "" h' e '" ~q 'j
/
9) Under which authority is the application made:
Estimated Cost of Proposed Work: $
Remarks: :J- S ;Qol/es u/',I! /;I?
f/,<;: /'c.~/j .rl,r~,U' ,-fe.
i./ nt!er (G '1 rf r I/,-t. 'I
?(;O~ 00
jJ; d;; //oJ /<//iP"",,,'k ~- fly 1/ r)tj('~
e/.{'cf.",~ Sel^/I/{:.r te hv...rf
,
Page 1 of 3
12)
Insurance Coverage: (Attach copy)
a) Insurance Company: A'otl,"t:/rr,d h/c;slu;'fla^
b) Policy # (X6!;6~'7 95"
c) State whether policy of certifica.tion on file with the Highway Depart-
ment: ~CCl; ny'M'rity ';//11<: <(7/0 A
d) Coverage required exten ed to the Town:
Bodily injury and property damage: $300.000/$500.000 Bodily Injury.
and $50.000 property damage.
13) Security:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
14) Fees for applications and permits: Basic
AI. / /Service Connections excavations
~
A2. I /Additional Excavations same
~
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
1.f.@$0.10-$
= $ If). 00
Additional
C. Excavations 18" 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.
No.
Utility Repair Excavations @$10.00 = $
Additional
Repairs same service @ $5.00 = $
F.
Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *
#SS~
-mi~
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~OUTHOLD. NEW YORK
(;g;@ ~
Peter W.' Harris
May 24, 2002
Date
Received by the Town Clerk
Date
Permit Issued 013 c/o ~
Date
Permit No.
/ 'i ::v
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
Highway Department
Town of Southold
Peconic Lane
Peconic, N.Y. 11958
RAYMOND L. JACOBS
Superintendent
Tel. 765-3140
734-5211
DATE:
6/;'1/ (i)..
TO:
.JJ-/I
jtlif T5/~'h)
/3(010)-
TIt(,
CASE NUMBER:
This is to notify you that Bell Atlantic and L1PA have been notified in
respect to the application for an Excavation Permit in the Town of
Southold.
fj{//rii?~' It 1yt
Signature of the applicant
[A~.C9~~~[.I'.jll.IIIIII~II'I'llillllllll................................ ;;i~~l~~
PROD THIS CERTIFICATE IS ISSUED AS A MAnER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PRAETOR MAGURK ROMANO INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
732 SMITHTOWN BY-PASS ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SUITE 300 COMPANIES AFFORDING COVERAGE
SMITHTOWN NY 11787 COMPANY
A PROVIDENCE WASHINGTON
INSURED
J & M LONG ISLAND INC
COMPANY
B
STATE INSURANCE FUND
BOX 2507
SOUTHAMPTON
COMPANY
C
NY 11969
COMPANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POUCY NUMBER PDUCY EFFECTIVE POUCY EXPlRAnON UMIlS
LTll DATE (MMIDDIYY) DATE (MMIDDIYY)
QENERAL LlABIUTY CX0568795 02 GENERAL AGGREGATE .2 , 000, 000
X COMMERCIAL GENERAL liABILITY PRODUCTS - COMP/OP AGG .2 , 000 , 000
CLAIMS MADE 00 OCCUR PERSONAl & ADV INJURY .1,000,000
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE .1,000,000
FIRE DAMAGE (Any one fire) . 100,000
MED EXP (Any one person) . 5,000
AUTOMOBILE UABIUTY AX0563583 02 500,000
X COMBINED SINGLE LIMIT .
ANY AUTO
ALL OWNED AUTOS BODilY INJURY
.
SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODilY INJURY
X (Per accident) .
NON-OWNED AUTOS
PROPERTY DAMAGE .
GARAGE LlABIUTV AUTO ONLY. EA ACCIDENT .
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT .
AGGREGATE .
EXCESS LIABILITY EACH OCCURRENCE .
UMBREllA FORM AGGREGATE .
OTHER THAN UMBRELlA FORM "1' .
WORKERS COMPENSATION AND 8671190 4/27
EMPLOYERS' L1ABIUTY 100,000
.
THE PROPRIETOR! INCl EL DISEASE-POLICY LIMIT . 500,000
PARTNERS/EXECUTIVE
OFACERS ARE: EXCl El DISEASE.EA EMPLOYEE . 100,000
OTHER
DESCRIPTION OF OPERATlONSIl.OCATlONSNEHlCLESJSPEClAL rT1:MS
TOWN OF
HIGHWAY
PECONIC
PECONIC
SOUTHOLD
DEPARTMENT
LANE
NY 11958
SHOULD ANY OF THE ABOVE DESCRIBED PQUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL OSE NO OBUGA N OR LIABILITY
OF ANY KIND UPON THE C
AUTHORIZED REPRESENTATIVE
..
New York State Insurance F and
.. . Wo!'tm:f C~m! &' Disability Benefits Specialists Since 1914
8 CORPORATE CENTER DR, 3RD FLR, MELVILLE, NEW YORK 11747-3129
Phone: (631) 756-4300
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
J & M LONG ISLAND INC
POBOX 2507
SOUTHAMPTON NY 11968
POLICYHOLDER
J & M LONG ISLAND INC
POBOX 2507
SOUTHAMPTON NY 11968
CERTIFICATE HOLDER
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
PECONIC LANE
PECONIC NY 11958
POLICY NUMBER
I 867119-0
CERTIFICATE NUMBER
548052
PERIOD COVERED BY THIS CERTIFICATE
04/27/2002 TO 04/27/2003
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 867 119-0 UNTIL 04/27/2003, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER
FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE
POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, EXCEPT AS INDICATED BELOW
IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/27/2003 IN SUCH MANNER AS TO AFFECT THIS
CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER
ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION.
THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE
SUCH NOTICE.
THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICY
NEW YORK STATE INSURANCE FUND
d.~>>I, IM1;:;;J.l.
DIRECTOR, INSURANCE FUND UNDERWRITING
This certificate can be validated on our web site at htlps:llwww.nysif.com/certlcertvaLasp
VALIDATION NUMBER: 646844897
U-26.3
I .l$JI..U "'.1 .1~
,
it
.U,.'
~"".."..,...,.",.,.,
"7"'""-~--
~"'--'~':r.7','7'7."":r:7"~--"""""-""""-'
I
\
\
\
\
, /~.\
/// ,",~., \
/ L1'~
''1l-\;
"\' I
\~
'S
~'S
oi' ~s"'"~
"I ~o~s\'
oS ..0
(,,~f;.~'
.
n
\It':r.
~~
",
-,~
~~:~
lIl:.lIl:.?
oo~
cc
~~
t~,
~~
'I,ll)
)
-...........
,'......
~
.
I
I,
~
",
In
lfi
v:
c>
~
~
"
\
"
<
, l'
\":1-\)~
.;.! ~
~i>S
"
u
o
~,
'"
,.,6
,~~.
LiLY
(LITTLE
{JON/')
OND)
"
"'~
,~
fl)(.tOf
0I0~~~~
'T
I
!
L
"j
'. ;:r
.._J>,
". ,<t,
, .
- r'
+~
,~
\~
,l
'\
,~
':J;'--'
.~.~
.
.
,_ 21'~
_.,,~
~ "
\"~~\~
\ \:
\4~1 \
,
,,,,,,,,,
,~.... ,..,,,
~
(.N~
m
"",)
-'"
cotlc. FOUtlD..iIOl'l
""", ",,,;o,,,.r.'" .4.Y
"y-
O ",
., ~
--'~- ".
I I
\ \
\ \
\'f, I.
I'
I", \
\
\ I
I \
-"
'"
'",
'"
t.) u
(O.S
~t)
.y~:
tIl-"...... "
207gB'
('lUeY'l' \,\\\.>l
.I
1\', \
,()f
,
-4:
.
-,--'-'--"~
?9\Jt\~) .
\l\Yj~
\~'
p... \l f,~ '-I \' ~ .~
,,,,,,
C()\~.~
.~\'oo" ~ ,"
S .0' J _/-<~'
JII''- -----=-.-.~i~"'"~-
---------~ -,,~
- -- --~-------
Town of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/20/11
* * * RECEIPT * * *
Receipt#: 100926
Transaction(s):
1 1
Permits
Reference Subtotal
698 $713.00
Check~:20563
Total Paid: $713.00
Name;
National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 698
Permit No. I
File No. {.~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref#T101201191
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 excavation 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) NATIONAL GRID - GAS OPERATIONS DEPT.- 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY
11801
Name of Applicant
2) Soundview Ave Southold
Address
Owner of Premises Address
3) Reolacine a leakine cas main on Sound Ave, starting at the intersection of North Rd., going west
780' west of Clark Rd.
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a} Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No. Plumber's License No.
X
s)
Electrician's License No. Other Trade's License No.
Si~ature of Al~plicafi~
04-04-1
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a H ghway Excavat on Permit
by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting Date:
8) Work Schedule:
Completion Date:
R~:CEIVED
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
Completion Date
201
Torn C~rk
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy it
c) State whether policy of certification on file with the Highway Department:
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 or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
A 1. /Service Connections excavations ~ $20.00 =
' trench fee
A2. /Additional Excavations same service ~ $10.00
No.
$150.00
+ 20.00 hellhole +30.00 for
6 bellholes
And .30 ea. foot from 101'
A 780' & 930' trench = 1710
B. Excavations 18" in depth or less:
0-100 1.£. = $10.00 -
l.E @ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. -
Additional If~.30 = of trench 96'
D. Excavations 5' in depth and over:
0-100 l.fi = $50.00
1.£ @ $0.50 = $
Additional
NO.
Additional
Utility Repair Excavations @ $10.00 $
Repairs same service @ $5.00 = $
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $713.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
NATIONAL GRID in accordance with this application.
Received by the Town Clerk
Permit Issued t'/t/~ O/~t t/ Date Permit No.
s~ENDENT OF HIGHWAYS
Peter W. Harris
S /bate
Note: Permit expires one (I) 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
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
ist
2nd
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC Building under Construction
WIP - Work in Progress
DB - Improper backfill (too high) (not sufficient)
HFS- Inspectorholding for final sett]ement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT
NO.
09:00
REQUEST FOR STREET OPENING PERMIT
[~ STATE ~ NASSA.
MIS JOB
LOCATION
REASON FOR
OPENING
W. OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
SERVICES
DATE
P. 02/02
?'-i- tl
DATE OF
OPENING
DIVISION ~.,
DATE
/O7- :2.1
DEPARTMENT
~*s co,sT,.a,~,T. ~
N
I'x 7,f~'
TOTAL P. 02