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Home My WebLink About970 Willow Dr ermit No. S 0-- TOWN OF SOUTHOLD HIGHWAY DEPARTMENT °ay Peconic Lane 's Peconic,New York 11958 0 (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR PLICATION IS HEREBY made t the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or re lations for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws, or finances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized in pectors to make necessary inspections of the job site. Pr nt or T e 1. n� Name of Applicant Phone Number Address of Applicant 2. V� Name of Contractor Phone Number Address of Contractor 1/77-4- 3. /7,Z3. Name of Property Owner Re que ting Service(if 'applicable) Address of Owner n 4. Viro—rk Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,o er Town permits may be required. NOTE: All information requested by this Signa of Applicant Application/Permit Form is1 cg 1 r Required for a complete application! Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of all site and pavement restoration work. (b) Attach all other necessary pe�nnits 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 No.: District1000 , Section Block �, Lot �0• 1 7. Starting Date: r-V Completion Date: ` Aaq 8. Work Schedule: Phase Completion Date Excavatior ! Work Schedule Facility InE tallation A 1 Must be provided Backfill&Completion CUQ1 for consideration as a Pavement replacement %) I n 1QQ WiliT Complete Application. 9. Under which authority is application being made: /— See Town Code Chapter 237(E)�-Provide Resolution by,or authority from,the Ctility being modified. 10. Estimated Cost of Proposed Work: $ 11. Remarks: D-39 1 of 3 1 . Insurance Coverage:(Attach Cop ) (a) Insurance Company: a(\A-)C- c� b`l Ins. CQ (b) Policy#: 2 LUI 1 d O J i (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extended fo the Town: Any Loss including Bodily n�ury,property or commercial injury caused by or attributable to the work performed: $1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: �n (a)SuretyBond � 1, C or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided:) 2 years or 3 years. 14. Fees for Applications and permits: _ ,,qq��, Basic Application Fee for Each Project Location, - $500.00 ( vUO� A Project Location would include each Bell Hole and/or every road opening or excavation within any 50'Radius whether or not they may be inter-connected by open trench or directional boring. The total number of Project Locations shall be subject to the approval of the Highway Superintendent. Al. 'Service Connections excavations @$50.00 $ - A2. /Additional Excavations same service @$20.00 $ No. B. Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; ® L.F.@$10.00 $ C. Trench Excavations 18"in depth to 5'in d Total Lineal Footage of Excavation; L.F.@$30.00 $ D. Trench Excavations 5'in depth and over Total Lineal Footage of Excavation; U L.F.@$50.00 $ E. Utility Repair Excavations @$1,000.00/Each $ Additional Repairs of Same Service @$500.00/Each $ ,No. TOTAL$ F. Oficial Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavati permit to: in ac rdance with this application and subject to th "General Conditions"and"Special Conditions"of permit(if any)a ched ereto. SUPERINTENDENT HI TOWN OF SOUTHO , Vinclnt M. rlan �a r Date Date Received by the Town Clerk q Date Permit Issued !1119 k Permit No. 1§P- NOTE: § a-NOTE: Permit expires one k1 year from date of issuance. No work to start wiihout 24 hour notice to Superintendent of Highways. Permit must be avahable at all times for inspection,on site,during construction. D 39 2 of 3 I I Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified I St 2nd 3rd 4t' (To Permit Clerk) REMARKS i CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavatio UIM Unable to Measure(due to bckfilling) B C Building Under ConstructioT Work In Progress DB Improper Backfill(too high, of sufficient) S Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 i I I I I --�- - -! -,- • --- - -�- - -- - - - ---- Center-Island-Services----- : - - 67 S - —, � -�--�--T -,� . --- - --�--- ------- --- -----.- --. - - camore_Street-- - --- -- Patchogue, NY 1117721l �-------T I ,---- ---, - - --I---- -- ------ �---TOffice:631 475= -- ,-� --- 5600, -- --'- - - -Fax,�(631)475- Contact': T-- --- - - -�- ! -------- - -- - -- ( )- 75-8830 ---,- ___ r 1 Contact: Sal Cipolla 774 8599 -- -� -� — Cablevision Project _r r---- i I I I , I ti' I I ' I � -�---�---�---•------moi- � ---,---- --'- �--- r--- - ---I ----- -•----,-- -•--- -�- -- -- -- ---�- --I - -----�-- �- ---- - -- - ---' - ------ --.- - -�� i-I ----�- --� --�-- I , •--, ---,----- I � -�-- i , ISI r--T----,- I I I I I I h I I I I I I -___i --r___•-__--•-rte-,-�___�____�-� ,--,_- ,_-_ --.-,_-_�_-�- r--. �-ice _,_--�-__-�-r _T N14Verizon UE fv-P-N1 12:24 PM WI AA myworld.cablevision.com 'CL x9a104 X) ft,, myWorld �'r+ Coaxial cable�n-so G EX In se P3.500 UXG 2100000000000000 z' 44 REPLACE FEEDER UNDERGROUND CABLE 220FT ON WILLOW DRIVE FROM 23 TAP TO 20 TAP IN FRONT OF 1 •------- • HOUSE 970 WILOW DR (D % > X9AI',04-23 (D Center Island Services 67 Sycamore Street Patchogue, NY 11772 Office: (631) 475-5600 Fax: (631) 475-8830 U. Contact: Sal Clpolla [General]CLEDEE Logout Bu.1tby0Ub11SenSe Load Status 00 Cell: (631) 774-8599 Cablevision Project#.. 1 -7 (42 7 Ll l . t ce Refers-M � 7HIRD PARTY DAMAGE Fmol CLAIM I Form Number. REFER TO: CONSTRUCTION ETSIRemedy Ticket: 00138375086 Facility IDept: Supervisor. D.Gree Tech#/Cell# 2235 CARLOS LEDEE REASON FOR WORK 1: CONSTRUCTION REASON 2- Pole: PS' Amp' Tap DESIGN INFO ONLY DESIGN Doslgn Type I TYPE1[:: AS-BUILT 2(Rm/Cemm) Residential Enieting/New Subscriber Repair Location: i CORP 7839 Account./ 369668.01 Date' APRIL 12 2021 Name: BARBARA BERBRICH Phone' Gnd/Map Address: 970 WILLOW DR X-Street' MOORE.S LN I Town: + GREENPORT Hagstrom. ;-:,AL ctude- R rR t td cable revillawmem Is needed = CorpHeadend Node CH2 CH70 CH119 603 MHz 693 MHz 747 MHz Tap Pre-Fault I Spliced Point: Ground Block: Tap Post-Fault Aerial Wodr(tlet poionumb.r}s)8,-, ngarasitiousan�u�teK 1=` TYPE CABLE REPLACEMENT POLE PED House @ 970 - Lock Box_ - >eox cover Needs Rep4:eartienr.�' � : ``�V ults} Pedsstais _• Is there a TEMP cable In lace at this time? NO Fla; Does the repair require a ROAD CUT? Fig: DRNEWAY SHOT #OFDRA/EWAYSj CONSTRUCTION TYPE UNDERGROUND CABLE TYPE: eptii FOOTAGE D • Is this a house drop? NO What is the drop length? Is there a spare cable? NO Is the drop Aerial or U/G? Underground REPLACE UNDERGOUND FEEDER 220FT FROM 23 TAP Fittings and equip.been changed? NO TO 20 TAP IN FRONT OF HOUSE 970 WILLOW DRIVE Comments. NO i Is this a dangerous situation? ---x'---_ _c: -'-,-z,-`—,',SIGNALL'EAKAGEMEASUREMENTS' C L I.Level @ 10 feet before repair meas. Locauon and repair of leak nabov.20uwm If leak Is generated from plant Identify the apprc.location of Home= ome Tap Drop Feeder Trunf• the leak and document.(irdornatian an this form. i CLI Level @ 10 feet after repair meas Pad Value(d used) Ois tch V# _-- - :DESIGN REFERRAL- - - - _ - - I -- - All desion referrals must have take off poles and foots es Drawnmust have exact location of cable droos and feeder if needed I Third Party Damage information Tech S Time worked 1 st Tech 2nd Tech 3rd Tech rhad ' (Construction Use Only) t_>Datei Received:, - _ _Tech(s)I Contractor assigned tor —Data Asslgnad: _ NCR(not dont related)r, 4 Back To;, NCR-Date Given Hack- jActual Comp:pate: - Joch(s)b Ccn:ractoi ijIi6 eohipteted diii work- ___,y, Complecien Code ,- ConstruFtion Completion Comments: Needs Activation YIN 'NCR iequ-res comment