HomeMy WebLinkAboutVillage Ln
~
Date: 04/24/00
Transaction(s):
1 Permits
Check#: 3207
Name:
Brooklyn, Union Gas
444 East Main 5t
Patcholiue, N Y 11772
Clerk 10: L1NDAC
Town Of 5outhold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
-tI Lj t
Total Paid:
3207
Subtotal
$45.00
$45.00
Internal 10: 9373
Permit No. tf~
File' No.36
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic, New York 11958
(516) 765"'31l10
PO. {2>01- /7B
Ref. 1/ d571J- oj
APPLICATION/PERMIT FOR HIGHW'AY 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 make; necessary "Inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
PATCHOGUE, NEH YORK
Address
11727
2)
Name of Owner of Premises
3) ~ 0\\
Work Des
Address
o cC,j't',."I ~ CJ II ( <.-T
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.
Electrician's License No.
Other Trade's License No.
,~t11~
Signature 0 I cant
'Y'd-J oJ
Date
5) a) Attach plot plan showing location of proposed.ex'cavation 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.
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) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11)
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
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or 3 years
Application Fee.....e~/
@ $20.00 = $ d-c> - (.,J
14)
Fees for applications and permits: Basic
A 1. --1-/Service Connections. excavations
No.
A2. IAdditional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth 'o'r 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 @$10.00 = $
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.
* **'
,
TOTAL COfIT' S
. .
If C;:'" (iJ
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: ~~.J tZ-L,';"'f~ ~'/'J' ~ ~~:)
in accordance with-this application.
SUPERINTENDENT OF HIGHWAYS
TOWN Q OUTHOLD, NEW YORK
//
Raymond . Jacobs
tf---r-o -00
Date
Received by the Town Clerk '1-Pl-/-t!o'
Date
Permit Issued,' '-/- tiZ-'I-Oo
Date
Permit No.
<16,
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice .to the Sl:lperintendent of Highways.
Permit must be available for inspection.
,
D-3S
\.
Page 2 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
Fe-611lA
o STATE
o
o
SUFFOLK
COUNTY
[E!
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
LA.JL .
cf;;s :;'iJ a
'oM'/ O,e"[:;/r
FOREMAN
00 '"
'i-V'AI ~;Ic, 1Z
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
SKETCH
N
{)d!:.JMtb.
Sf:
'.
~
~I ~- -- - - - -
c::::: -
F::~ -
:h ~
V\-
t"\ ~
"
N
~ \J\
'.
tI
I '"
<-
l;
~
^
I :St>
~ ~~~
~. "'-' ~
f"\ ~~ ~
I..!::I'~
""
~
! A I
I ,
lk
r
-------?
t}:--
HtrLLod{
BCD~.
Permit No.,( 7
File No. eX 7
DIU",,,,,
.-wi/"....
'-~ !c1-7/<D
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT'J-~' 6
PeconicLane . RI1 2 2000
Peconic, New York 1195(# LjS'e;3
(516) 765"'3140 ,~"
Po. /2>0 Y- /7f> -.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
:;) Lf Y-17-o3
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) BRoo):::1 tV L{ N I 0.->
Name of A plicant
C--tr8
P t!' ()1 f --.J Sf
Address
/t-rd(j'-<<
2)
Name of Owner of Premises
3)
'"'I c;. u \ \
Location (Street
Address
7S ~% CJr(d,~ -d(ZU:,J!
Hamlet, Cross Street)
(a) Is construction los;ated within 75 feet of tidal wetlands? *Yes_No ...p
*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.
~2f~
) (J-Y/OU
Date
5) a) Attach plot plan showing location of proposed- elCcavation 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) Tax Map: Section Block , Lot
7) Starting Date: Completion Date
8) Work Schedule:
Phase
..
Completion Date
Excavation. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
Facility Installation.................... ...........:..
Backfill & Compaction..............................
Pavement Replacement..............................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
\
D-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
total amount
Maintenance
or Certified Check
provided in the
b)
of $
Bond provided:
2 years or
3 years
14)
Fees for applications and permits:
A 1. (/Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ d 0 ()
No.
B.
Excavations 18" in depth or less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
liS
0=
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 @$10.00 = $
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
issue a Highway Excavation Permit to:
in accordance with .this application.
Town Clerk of the Town of Southold to
1i,(J()//KiYA-J I.hV/P~ G/l-S
TEN DENT OF HIGHWAYS
F SOUTHOLD, NEW YORK
00
Received by the Town Clerk / - oZ &, - 00
Date
Permit Issued, /-027- 00
Date
Permit No.
cl7
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
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
I nspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
/
REMARKS
/
CODE
IB - Improper barri,cades
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 - Inspector holding for final settlement of excavation
RFR - Ready to repair
\'
0-39
Page 3 of 3
,
"
Cf :"v"'Drooklyn
}/ Union \(" rz /), Lf ,) i-
,.<"'1 (JeOO} OAS.2001 \-......
Cl'STOMER NAME n .),
t'"ch.cv'.\ l"t-vv'"
SEK VICE ADDRESS l' " ,10
I 'i 0 \I. \ \,,,,, ',''')''
)I.IILlNG ADDRESS /' 2E;;5i-J ML:' _.\ I?.qrl (Y,<," I ''''Sf
CO:-<T~'17TOR ~AME~, TCONTKACTOR l'IIONE llUS/NESS !'IIONE
, IVI,. ..L\ (O,)V,o,:.\'""LJc 3''J...-\o,'),?,
SERVICE N/S . 0 SlS r~ Els )( W/S OF V. I k.::;.e i A.~'(,.
LOCATION :S 1 ~ rt' 0 N/O 0 s/o;6}/o 0 w/o <b_es:~:;)
nUSINESS REQUIREMENTS
/s Gos COI,"eity Request Required?.. ,.. l(No [J Yes
'~oo 0 Yes
o Yes_
.'
No Work Required........ 0 New Gos Main w/Serviee .....0
Upgmde Meier... .......... 0 Service Upgrode.....,.... ........ D
New Meter... ... ............'~ Service Reloealion...... .........0
RiserlHeoder Work........ 0 Meier Reloeotioll...... ........... 0
New Gas Service Loleral Q/ Existing Building... DYES ':\2I'N0
SITE INFORMATION
CHECK USAGE BTU INPUT/lilt TIIERMS/Yi\ Square Foola~e lIeated Space
L;lIge Meier :..Type Size
EX/STING LOAD AeeoullII/
NEW SPACE HEATING! /0',-0,:::=' /c,-08 Grid 1/ /1'1- zg"Z-.
NEW WATER HEATING ' RC);ulalor Size S:-/Av./A"I
NEW COOKING I 6,-;1 tJz>C) 110 Ill,House Pressure 5-/~cl"" J
NEW DRYING t New Rale Code 1(0
NEW PROCESSING Degree Days I , 2 '7
TOTALS /.r;-'lc= / / rf' DOllE Faelor I, :; 0
IMPORTANT NOTIO; TO CUSTOMEI\S HEQUIIUNG INSTALLATION OF A NEW IlHOOKLUYN UNION GAS PIPE
By Signing below, I am certifying thaI I /Jill lhe owner or have Ihe pCrllli.~siol1 of Ihe owner III Ollllhori/.c [he jl1~I:lllalion of BrooU)'1l faclJilic.~ III :his properly. I
further lllldersltlJl(.lll1at iflJrooklYll Ullion ill.~lall.'i OJ llCIV ga., pipe al my req"e.,l, :llld [do Illll U.'ie tile .'icrvice lbl I III 1J.\ I P;IY I]rool..-lYll Ullioll for lbe eillire emt oflhe
imlilllation in nceoruanec wilh Kcy$pau Gas Corp's Jill/a IJroollyn Union Gas T:uiO; Leaf No. 12^. Scclioll 2/J, .I.'! n;<; approved by Ihe Public Service
COlllmission. I also undersland Ihat Brooklyn Union is not responsible for repaving or l:lIHhearil1g OJI privnle properly. I l\;lvC rcad nut! ngrec 10 lhe Gencral
Hcquircmcnts And conditions of the reverse side,
Customer Name: (print) ~e, <udR/
~?jg/==
~ .
-
__ _____.~_~.________.__ .-.____--0__.__.---- __ ______ ____ _.__
Is Regional EnglEngineering Req? ......
Arc excess Attachment CILlrges Required?
WORK REQUIREMENTS
/'
. A Maeodam D None
o Conerele DTree
~. Dirt/Sod 0 Sleep Incline
'0 DUG Elcclrie
o Customer to remove/cut back bush
o Customer 10 install protectioll posts
o Customer 10 install pad I'
New Service Diam -.l..........
Meter
Existing Moin
New Main
Lenglh 10D
)'Q Oulside
MI c, I
I ~~~Ct' 'I
o Inside
Dim" ...2. ~
Diam =-
Length ~
Mctcr Ordcr 1/
Work Order 1/
One Call Case 1/
GAS USE
Cus(oll1crIBU Ag,rccl11cnt Dale
-_r."
;. .)-(
IU~S1DENTI^L GAS JU:QUJSST JiO/{M
KeySpan Gas Corp. d/b/a/ ll.'ooldyn Union
BU !{~P Nt\I\.-IE
:'C.". .'-(
TOeN
)j-;e;...)....,
lIOME PlIONE
BU REI' PIIONE
'7 r:-"'.. .," I' .--1 I
,It;. "_'
ZII'
'1\ l/\ S-,
PLEASE INDICATE STAGE OF CONSTKUCTION
rLE^S~ CIII::CK
o Found.1lion 0 Fr.u"cd WEneloscd
\vi., ,',-'., \
5'1,
~
~
0.
"'
CUSTOMER AUTJIORlZATlO;!
OF METER LOCATION
__ Iii 1\.\ ,,\, L-"'^l1
j
,,1/
- -
1"/ I '"
----
L' .",(
z'
'1"-
~I
u
u
~
V)
Slrcel
D Cesspool
OOil ~1nk
o Sprinkler
D
,
COMMENTS
it!.
r
D\
\ \O,(c.
,,' ~
'- i ~ \-. ~-;;::,.......,
\r::>.e,,1;:
""::.:.":'::-Vd...L
l_c'-- \
C"::'-:-;"J-<...:l: (>C
.vz,,,.:.-hc,,.y....\('_
G{;;"<-_",,,~
C"""__. '0v--<.--- 1.....:.(,(\.'-
<:, "k ..' (C c;, \ \"'y'" "^-,<"
Pres (oC)
D..Relllole
Pres c'D
~-\;.,-..-sc.. \ <.
l'-- i, r <:
l...A.~) '...- '''':'<---~I ,-,:",- ,~...r:-..:., ,-_IL.
Pres ----==
00';) L/ ~Cj 9030
'7 "7'00 Oo"'~
('. O.J 0 I "")'-"
1'100
'77S
/, '-
Customer Sig: /~ ,vdl...k~
I3IU Rep Sig 4// ~/c;/
/'
DOlle -7rtN 18 ,/x:rc
,
'2-(11
'--/-
-~
ir-.-
i!
L.,
I TO THE
, "om"
'"
j
:1;
;''''-
730
MARKETSPAN CORP.& SUBSIDIARIES
PERMIT ACCOUNT 2
448 MAIN STREET
PATCHOGUE, NY 11772
1-32/210
DATE / -;) YOU
$ Y5~
DOLLARS f!1:...."::
_......-
-~
29941 Patt:hogue Office
Palchogu~, New York 11772
FOL ;) V f? 9 9' () ?
#>)7 j/::zr "'0007:10"'
__ (l",u>>-r
....~ ..- Y_.-:~-
1:021.000:1221: 9:18bl.
ELIZABETH A. NEVillE, TOWN CLERK RECEIPT 07707 0
Town of Southold
Southold, New York 11971 7/L/
Phone: 516-765-1800 DATE -r-2-.L. _.,1 7_ - - IS: c2ccC
RECEIVED OF Of;) i//l--P.P ;L/1J /! ""-"7) Cen_IV $._Y0 ec:___
f I
FOR # ~7 JritA 0- r.--f/l tV J PtU/vlof ~ ~'H'~
- ~
:l!~U~r- tiU4LL. - ~"-~- - ---- ...-. .-'l~
~~~K~ 7dO BY ,//~~.<.--'
Permit NO.~
File No.~
-.
TOWN OF s,:,U ,'HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic" New' York 11958
(516) 76sc31110
Po.i2>o'f- 175
APPLICATION/PERMIT FOR HIGHWAY EXCAVATI
'.
Ref. II;) 3'0 1'{5i'0 30
APPLICATION IS HEREBY made to the Superintend
of Southold for the jssu~nce of an E>cc:ava,tJon Permit pur'
Code of the Town of Southold, Suffolk County, New YOr
ordinances or regulations for the excavafion herein desc:r
to comply with all applicable laws, ardin,inces, codes and
authorized inspectors to miake,' necessarY,,:(nspectlons of th
Print Or Type
1) KEY SPAN ENERGY 448 EAST MAIN STREET
Name 0 Applicant
PATCHOGUE
2)
Name 0
wner of Premises
3)
J ,;1
Work Oesc
ption
L...i4
and Location (Street Number,
/ '3/
3oc). 7a
(a) '''5 construction located within 7S feet of tidal we
*If yes, other-Town permits may be required.
q) Builder's License No.
Electrician's License No.
Other Trade's L
5) a) Attach plot plan showing locatiqn of proposed.
adjoinrng premises or public 'stre.ets or areas,
ticn of layout of excavation. "
b) Atfach all other necessary permits and licenses Fol'"
c) Work covered by this application may not commence
Highway Excavation Permit by. the Town Clerk.
Excavation. '" ..,........ ....... '\:" ...,....,..,.,.
FacilIty Installation.....,.., ..;...... ............ ....
Backfill & Compaction"....".:...."...,.,..,...,.
Pavement Replacement........ ~'... .. .. .. .... " '" ....
9] Under which authority is the applic~tlon made:
10) Estimated Cost of Proposed Work: . '$
11) Remarks:
\'
AND REPAIR
: of Highways of the Town
nt to Chapter Bl of the
.and other applicable laws,
d. The applicant agrees
L ulations. and to permit
1i1ob site.
11727
V
Street)
dK.lC.....:r
*Ves_No
V'
No,
No.
"'--
n and relationship to
Lng a detailed descrip-
of a
:
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
bJ Policy #
c} State whether policy of ce'rtification on file with the Highway Depart-
ment:
d} Coverage required extende~. to the Town:
Bodily injury and property damage: $300,000/$500.000 Bodily Injury,
and $50,000 property da~age.
13) Security:
aJ Surety Bond or Certified Check
total amount of $
b) Maintenance Bond provided,: 2 yea rs or
provided in the
3 years
14} Fees for applications and permits: Basic Application Fee........$2S.00
A 1. i IService Connections excavotions @ $20.00 = $ ~O. ~
~
A2. ~/Additional ExcaVatio,ns same service @ $10.00 = $ / ~()
B. Excavations 18" in depth 'or: less;
0-'00 I. f. = $10. 00
I.f. @ $0.10 -,$
Additional
C. Excavations,"'S" 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 Repai~ Excavations @$10.00 = $
No.
Additional
Repairs same se:rvice'@ $5.00- = $
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *,',
5.5.00
TOTAL CO~T- S
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
Tq.w~", ,.. ""
'.' ..r~
.' Raymond L. J s
/-'7- 01
Date
Received by the Town Clerk
Date.
rf9
Permit Issued,. / - I,b-o I'
Date
Permit No.
~:
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.
Page 2 of 3
~
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
FC-6111.4
D STATE
D NASSAU
COUNTY
D SUFFOLK r-I " O. Sav'1!10L b
COUNTY ~
PERMIT I ~IS JOB TDATE
NO. NO. /-(,-01
LOCATION r= Is. III L LoA ,"r _ L-.4 )00 I sh f1.4{N I2D . (J~(EN""
REASON FOR ,
OPENING 31 It VICI, v<.tOC-~bt.
W.O./PA ? S -07t/':;'t-()30 FOREMAN TDATE OF ASAP
NO. OPENING
REQUESTED 04fJ MMfO DEPARTMENT I DIVISION & C f1..d -Z-t.{
BY GAS CONSTR. MAl NT. & SERVICES
APPROVED IDATE
SKETCH
~A.(\)4 flc.f~Z.7- 'iRoC;
N
eD
MA-IN
oJ'
--rr
1 ~
..)
.
~ ~
~~~
.., .., -
<.kt:
"Il'i:lc,
'tt
~
<o\l
.c ~
-
...., <"(
~~
l/I'/{l{l
J ofH)I/IJ(,.~
-.J, .
i I
~
..
Date: 01/16/01
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 1108
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
InternallD: 24734
Date: 08/16/01
Transaction(s):
1 Permits
Cash#: 1276
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1276
Subtotal
$55.00
$55.00
Internal 10: 38793
Permit ~o.-r-W
File No'--f~J
Ref.
TOWN OF S;'U,'HOLD
HIGHWAY DEPARTMENT
Pcconic Lane
Peconic, New. Yorl< -11958
II r:: f< 'H '-I't '1 7 (,,;)0 (51 G) 7 G5c 31110
- PO. {2,01- ,7&'
APPLICATION/PERMIT FOR HIGHW'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, Suffoll<: County, New York, and other applicable laws.
ordinances or regulations for the exc()va,tion herein described. The applic.ilnt agrees
to comply with all applicable laws, ordina.~'ces, codes and regulations, and to permit
authorized inspectors to I1'iakc; necessary.Jnspcctions of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicont
11727
llATCHOC:UF.. NEl-l YORK
Address
2)
Name of Owner of Premises
Address
3)
L,4r OVLl e ~ l
tion and Location (Street Number, Hamlet, Cross Street)
Is construction located within 75 feet of tidol wetlonds? .Yes No ~
.If yes, other~'Town permits may be required. -
(0)
11) Builder1s License No.
Plumber1s License No.
Electrician's License No.
Other Trade's License No.
5) a) Attach plot plan showing location .of proposed. e)(cavation 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 perml.ts nnd licenses for this project.
c) Work covered by this appliciJtion may not commence before issuance of a
Highway Excavation Permit by .the Town Clerk.
G)
7)
Tax Map: Section
Blocl<
, Lot
Completion Date
Starling Date:
8) Worl< Schedule:
Phase
Completion Date
Excavation... .... ... ... .. ... .. .. ...~........ ..........
Facility Installation........... .......................
Bacl<fill & Compoction......... ~....................
Pavement Replacement........ .':'." . .. . .. . .. . . . .. . .. ..
9) Under which authority is the opplicotion made:
10) Estimoted Cost of Proposed Worl<: $
11) Remarl<s:
\
(Y\ ~~\::l ~~ 1r-; ~~Tok
1)-1'1
Paqc 1 of 3
.:..
12) Insurance Coverage: (Attach copyl:
al Insurance Company:
b) Policy"
c) State whether policy of ce~tiflcation on. file with the Highway Depart-
ment:
d) Coverage required extende~ to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
aJ Surety Bond
total amount of $
b) MaintenClncc Bond provided:
or Certified Check
provided in the
3 YC<lrs
2 years or
111)
Basic AppliCCltion Fee........ $25. 00
excavations @ $20.00 = $ ,2 0
Fees for applications and permits:
A'. I IService Connections
"""NO:-
A2. , /Additional Excavations same service @ $10.00 = $ 10
"""NO:-
(,J
B. ExcavCltions lBlI in depth 'o'r: less:
0-100 I.f. = $10.00 .'
I.f. @ $0.10 -:$
Additional
C. Excavations...le" in depth to '51 in depth:
0-100 I.f. = $30.00
.I.f. @ $0.30 =:$
Additional
D. Excavations 5' in depth an~ over:
0-100 I.f. = $50.00
I.f. @ $0.50 =', $
Additional
E.
Utility Repai~ . Excavations @$10.00 = $
No.
Repairs same service '@ $5.00 ::: $
Additional
F. Notice to public utilities proof must be provided and attached to
this Clpplication prior to issuance of permit.
.'
* * .'
TOTAL con. ~S S-. cP
AuthorizCltion is hereby granted to the Town Clerl<. of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance wi th ~this application.
-NDENT OF HIGHWAYS
SOUTHOLD, NEW YORK
J?-~ /<y--O I
Date
Received by the Town Clerk
8/ 'IA (
Date
//'1
Permit Issued,'
E?/,IIL IO(
Date'
Permi t No.
~:
Permit expires one (1) yeLlr fr:om Date of Issuance.
No work to start without lIB hour notice 'to the Sl1pcrintendent of Highways.
Permit must be available foririspection.
Page 2 of 3
~ 0"
~,~""r
""""'....
'i/,'" ,",
;j:f:":
.',;,:-
,,','.
~':y:,
",'
~
.~.
'- ?'
.......
~
t
",_"T.
"'~ ..j
~:"'i'"
313'
"
u'
/LLa.,e
)... ~J
I
I
l-
"1
I
lVc,r
:J;l 'f ""'- 9 I
\
.....".~,~
';,'c.' ..,
.' ..~c~4>,
. ',' >":;:}{/~-:'::
~;::,",r
,,-:.;':'
~;).<.~-:-:;':
" "'''~:>
;::;{:Y::/'''' '>'"
· : ;\i:fi.\;~;(~.',~;
, . . ,'" ~'"'.\~ u)5~"';'
T~,,""f'~' ~~~'''j' '0
~ :~::~t.,~:~f, .
., - . ,....,~
.' ':,.~:- ,~,". {~'i-:C "
"\..
"",
;,[;'
-,,-.,..-:
'"""'.,.,.,-
'n:7X.":~l!I'
r
~4-
.\;'
II GIJf
7"
,4. N'fr
#$'
=...~,,...,--cr- ......----."'7':~~~--
"'",1
1
':j
'1ir
.-~~
'If,;'1f$.
.;::L'
',~
I
,
J
..........