HomeMy WebLinkAbout805 Kayleigh's Ct
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Date: 04/24/00
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Check#: 3207
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
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Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
~ll
3207
Subtotal
$45.00
$45.00
InternallD: 9374
Permit NO: .
117
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TOWN OF SQUTHOLD
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic,. New'York 11958
(516) 765'- 3140
P. O. f2,c>~ /76'
. File'No.
I
, ;J Sf/,;) -0.3
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,
ordinimces or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinal-i'ces, codes and regulations, and to permit
authorized inspectors to mlal<e; necessarY;,i,nspections of the job site.
f:.".
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Print or Type
1) Brooklyn Union'Gas East
Name of Applicant
448>,'East' Main St. 1" t h' N Y 11772
"a C ogue, ....
Address
2)
Name of Owner of Premises
Address
3)
',- C fY\A([ l -' -
Location (Stre7t Number,
" I kdLe
Hamlet, Cross Street)
(a)
fs construction located 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 ~IV'-~-A-
. .... .'. Signature of I dmt
,', Y'dv-cD
Date
5) a) Attach plot plan showing location ,of proposed<el<5;avation 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 applicatiollmay not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
"
Block
,. , Lot
Tax Map: Section
6)
7)
Starting Date:
Completion Date
8) Work Schedule:
Phase
Completion Date
Excavation. ...... ....... . . . ..0"... ~. .. ......... ..... .
, \
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) Poli~ # \
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:
~) Surety Bond
tota I amoun t of $
b) Maintenance Bond provided:
or Certified Check
provided in the
\/14)
Fees for applications and permits:
AI. LIService Connections.
No.
A2. IAdditional Excavations same service @ $10.00 = $
2 years or 3 years
Basic Application Fee..... ~
excavations @ $20.00 = $ dO, c:'\.l
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
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.
* * *
-n. .'tU-cY
'/ul't\l d,
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: . MA~?7~ I.//J.ni) rf? / ..
in accordance with .this application.
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD. NEW YORK
tf-- U:? - ?7?'
Date
Received by the Town Clerk -'/- ol-/-tJo
Date
Permit Issued,' <j.. ol...l/-Oo
Date
Permit No.
<-/7
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
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CHECK USAGE BTU INPUT/Hit THEltMSlY1t Sllu.re Jlllolal:e Jle:1led S\).ce ) '70 U
Large Meter :..Type Size 2 76-
EXISTING LOAD Account II
NEW SPACE HEATING v /30,= 1'1-1'1 Grid/l IN-13~.:>'
NEW WATER HEATING v 46:.'>2>"1$ -0 ltegul:1lor Size .I
NEW COOKING i/ ~ ,,~'..vr:, I S'() In-House Pressure 5ko.--h-.1
NEW DRYING v 20 ,7;!:'<!/ " New R:1le Code I It)
NEW PROCESSING / Degree D.ys 1 I Z'/
TOTALS . <J _ '-i Dom, r:1clor ,,' . '!
IMI'OH1'ANT NOTICE TO CUSTOMlmS ItEQUJI ING INSTALLATION OF A NI,W llHOOJ((,UYN UNION GAS I'JI'I,
fly Signing below, 1/1111 certifying thai 111111 Ihe owner nr have the Jlermissioll of lhc uwner III lltllhurizc Illc in.'tIOlllllliun lie Brnol:lyn facililies nllhis properly. I
fmlher ulHlcrsl:llltJ Ihal if lJruuklyn lJniulI insl:llIs:1 lIeW gas pipe :11 illY rC'I"esl, and I IIUIlUIllSC the service 111:11111111:;1 jl;IY UrllllU)'ll tJlIiull fur the clllire (usl of Ihe
ill~tllll:llioJl in IIcco"Jallcc wilh KcySp:lII GIIS Curp's dth!;, Brouklyn lJllilHl Ga... TlIrin: I.eaf No. 12A. SeetiulI 21J. ,1.'1 /I." uppruvctf by Ihe Public Service
Commission. J also understnnd Ihnt Brooklyn Union i~ 1101 rc.~pon:'iihJe ror rep:1vinC or 11llldsc:Jpillg 011 pri"lIle properly. f '.<lVC rC:lJ nntl agree 10 Ihe Gencrol
ItcqlJir~R1cI11s Inti condilions orlhe revcrse side.
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1 (XOO O^-~.200 1
ClISTOMER NAME
SEll VICE }J>DRE.'S
/
K/~ L/ LE ( 6/1 (S If) Lire;
/ I 'i
CONTRACTOR I'UONE
Is G:1S C.p.1city Requeslllequired'/.., --. No 0 Yes
Is Regional EnglEngineering Req? ...... ?\No 0 Yes
Are e;l:ccss Allaehmenl Charges Required? i(No 0 Yes
WORK REQUIREMENTS
No Work Required........ 0 New G.s Main w/Service ..... [,
Ul,crade Meier... .......... 0 Service Upgrade...... ............ D
New Meler..................li( Service Reloc.lion...... ......... o.
Riser/J-Jcader Work........ 0 MeIer Relocalion... .............. 0
New Gas Sel"\'ice Lalera( Existing Building... DYES .~O
SITE INJlOllMATION
'61' Macadam D None
0' Concrele ' o Tree
J:( Dirt/Sod oSteep Incline
o DUG Electric
o Cuslomer 10 remove/cut back bush
o Cuslomer 10 inSlallproleclion posls
o Cuslomer to inslall pad
. ..
New Service Diam
o Cesspool
DOil LllIk
o Sprinkler
o
presG,O
MeIer
Existing M.in
New Main
o Inside
D i.m ...z:.-
Lenglh 102-
~Outside
Mil PI,e,,-, it-
o..Remote
Pres~
Di.m ,-
Lenglh -
Meter Order II
Pres
Work Order II
One C.lI C.se #
GAS USE
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COMMENTS
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t/ace
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Customer Name: (priot) K\ cAt A-i2 w '"I; e.A 'i L
ClIslolllermU Ar,reelllelll DaTe_5J/zb.:r=-c
CustomerSig: \12" aIN..J...~Q__O
DIU RepSig: .~~#//
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Dale
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