HomeMy WebLinkAbout2395 Village Ln
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File NO.~
Ref. n
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TOWN Or- 5:)0 "HOLD
I-IICI-IWA Y DEPARTMENT
Pcconic Lane
Peconic. New' Yorl< -11953
(5,IG) 7G5c3PI0
Po. (d,oY- ,78,.
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APPLICATION/PERMIT FOR HICHW'AY EXCAVATION AND REPAIR
APPLICATION IS HEREBY mode 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, ordina!,l'ccs, codes and regulations, and to permit
authorized Inspectors to make; necessary. inspections of the job site.
,
Print or Type
1) KF.Y ~PAN RNRRGY 1,loR EA~" MAIN ~TRRRi'
Name of Applicont
~ATCIIOGlIR, Nm/ YORK
Address
\1727
2)
Name of Owner of Premises
Address
LA C! r<-'e,~ '\
(Street Number, Hamlet. Cross Street)
1V
(filS I~A-K
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3)
;)'S9s- lJ\\\tI-~..
Work Description and Loc lion
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1's construction located within '.75 feet of tidal wetlands"? *Yes_No
*If yes, other""#'!own permits may be required.
....
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II)
Builder's License No.
Plumber's License No.
.......
Electrician's License No.
Other Trade's License No.
.:,....
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r-12 d J
ate
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5) a) Attach plot plan showing locati'on ,of proposcd,-ex'cavCltion and relationship to
adjoining premises or public 'stre.ets or areas, and giving a detailed descrip-
tion of layout of excavation. .'
b) AtriJch all other necessary pcr~i.ts and licenses for this project.
c) Work covered by this iJpplication may not commence before issuance of a
Highway Excavation Permit by, the Town Clerl<.
", G) Tox Mop: Section Blocl< Lot
,
7) Starting Date: Completion O<lte
.
6) Worl< Schedule:
~ " Completion Date
.\
Excavation. .. . . . . .. . . . . . . . . . . . ... ~., .. . . . .. ... . . . . . . .
,
Facility Installation...........::....................
Oacl<fill & Compaction.........:....................
Pavement Replacement........ ":'. ~............ .. .....
9) Under which outhority is the opplication mode:
10) Estimoted Cost of Proposed Work: $
III Remarks:
"
0-1.
Paqc l' of' f".' - ""
~
....
12) Insurance Coveraqe: (Attach copy):.'.',
a) Insurance Company:
b) Policy II
c) State whether policy of ccr;tlfication on, file with the Highway Depart-
ment:
d) Coverage required ex tend~~. to the Town:
Bodily injury and propci'ty damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
aJ Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
111) Fees for applications and permits: Basic Application Fee........ $25. 00
A 1. -L/Servicc Connections 'excavations @ $20.00 :;:: $ I
No.
A2. IAdditional Excavations same service @ $10.00 ::;: $
~
B. Excavations lOll in depth 'or. less:
0-100 I. f. = $10.00 .'.
l.f. @ $0.10 -~$
.'
Additional
, .
C. Excavations...tBll in depth -tQ '5' in depth:
0-100 I.f. = $30.00
.I.f. @ $0.30 =...$
Additional
o. Excavations 5' in depth an'~ over:
0-100 I.f. = $50.00
I.f. @ $0.50 ='.$
Additional
E.
Utility RepairExcavations @$10.00 = $
No.
Repairs same s'crvice'@ $5.00 ::;: $
Additional
F.
Notice to public 'utilities proof must
this application prior to issuance of
: ~.' .
be provided and attached to
permit.
11 11 .;.'
1~OT^I. r.O~T ~ . y .~
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Authorization is hereby granted to the TOW;:;;erl< of the Town of
Issue a Highway Excavation Permit to: . .J \. )rr; .'\ I
in accordance with ~this application. .,' I
Southold to
DENT OF HIGHWAYS
OUTHOLD" NEW YORK
"
Raymond L. Jac
9- i'l-O/
ate
Received by the Town Clerl< q - ;Zo - O~
Date:
Permit Issued,'
9c;(/-D/
Date
. Permit No. I/: / OL/
~:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without 118 hour notice .to the Sl:Iperintcndcnt of Highways.
Permit must be avai1"able for inspection.
Page 2 of 3
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~.. , LEAK LOGGED IN:
TOWN QAID XV SIDE HOUSE NO. PRE STREET '
011:).1' [IPtlLl biC9.lel~11 S :l3<iS I V"\~
FT. FROM
CLOSED:
SUFFIX
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LEAK NO.
L 365255
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Perimeter IZl
CIled<ed
MTRlt ~ 417 aUf"
o OPAl.,. .3 I /~L. /
Choc*odJZl' IINrrw.~ ,I /
Inside J I
REClASSlFlCAlKlIIif
DATE EMPlOYEE NO.
DlR CROSS 8TREET SOURCE, 0 CJ.8URYEY 'DUNE PAm''''UR''E'' 0 R". S\IC. AREA
t..\ f\VY ~ l.Ji!1CDCRINVEST. 40~WCRQ 70_....NSURVEV · UNEVAl,V, ~ L
I' zO'YRSURVEY &OVALVEPIIOORAII 8 JSUBSTRUCT.SUR'/E'l 1.08.P... T
ATE 1M LEAKCLABB ~.~~~ SIZE 603' lzD 16' TYPE OF
q / / DfJlj O. OZA ~Z 03 READlNR, 10\\' 704' 13020" SERVICE
I 0110 FAClLnY SoSERVIFOOND. ~~h zDw- aDa' 14022"
q I ~3 1DTRAHS tt.s"*'Of-b51
/ /01 I .... ."'''". 3D" 9Da' 'SOZ4'
U 2Ji!l1lI8T 8oSERVIS"'" INSTALLED
ClSPAT"HcD 3oSERVlTEE-CUOB 7OvALVE_l 40 IV,' 100'0" 18026'
./ / 40SERVIMDPNT aoCUOBVAL"ElSERVI snz. 1In,Z" 17n3D'
ARRIVED PRESSURE INSIDE SET PAVING MATERIAL
/ / 10 LOW loDit 4oMacodlConc_ IDs.... 4 o Cull..n
.0"ES
ZoINTER... zJj!l_ 5oR- ZoP~Hl.lIe soCqlpor
/ / 3121 "Mi" Z 0 NO 3 0 Conot... Concrel. 3 0 PIoa.. 6 0 W_I...
MHRS ROA 'TYPE ~TDMER""'" ~'
lo_vy 4oC"Y-lGhl U~""... rn..SQ"U.... ~'Z.J- OCPqz..
ZoSlale-lQl< SClOlha'-Hvy "".uw~, IIOTT1.ESAMPLEQ POS
30 Cnly-Hvy 612l01hl<-l.QI1l I I NEG
, R_9N......B.-.g~ ;ZOC1~ond..~n.lram_. Bartlole'L-
Z Rollllngs;nContinuouoly P.vodAtaa ."0 No 121 I R-.;& losIdaCt>b Y"IZI NoO
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4 F....COndIUon. ."0 NoI2I I D__Job ...0 Noel
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FOUND BY: ~"I
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C~~F1ED BY: (EmpI.B1
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ASSIGNED TO:
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REPAIR EMPLOYEE'
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REPAIRS COMPLETED BY:
I I I I I
W.O.JPA NUMBER
'DRoaId'I
zD Comm1
lINE
'CALL:
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FROM TO
SKETCH.
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CURB OR CCNTINUOU ..v PAVED AllEA
SHOUi.peR r 50' or-...
n r3O' _ ..-..:.:...;j h=='s'_ 20'-1
a:: or LoN Thon Nt'( READING, TYPE 1 L'" ...!."""
Any V:;;;.';' T~Z ~I.EAKSONINSlDEEX1'08EDpt""" T~Z
Reading ,- NEED NOT BE Cl.ASSAFIED BUT YJST FOU.OW ,po-
Type 3 loMThan 1~(W PAOCEOt.IREFORMEOIATEeuMlMTtONOF 2QfM.or
T~3 f=~ POmmALHAlARD. ~
Addl_ Work Required CJ.o CJ No BAIIHDU! IDENllFIC R&ADIN
Now'-' . IlaIa DATE 1 2 3 4 5 6 7 8 I 9 10 11 12 13 14
~~'~::"~>~~'" ~~'. ~:~ ;:;; 53 ;: ;tOSSI,,, 00 (). ~ 60 ~.. ~_
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I]] GAS DESIGN & CO~~TrE~CTlON LEAK TICKET
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03.
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UNPAVED AIIl!A
50'-+1
CURB OR
SHOULDER
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rGteater
Typos:"'"
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_30'll0
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Any
Reading
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SEOUENCE HO.IIl REP~R 00 0Cl00' MDNGfT 0100 - 1.-00 AM
t'.. REOECK 8O-OI(MerR....... leoo.S~OOPM 2200..'0:0)""
FC-1Q62t....SS
Date: 09/21/01
Transaction(s):
1 Permits
Cash#: 1306
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
l
*11---
1306
Subtotal
$45.00
$45.00
Internal 10: 40246