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Home My WebLink About1440 Kimberly Ln ermit No. S TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 c (631)765-3140 A�Y�1 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR PLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit pi rsuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or re ulations for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws, ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized impectors to make necessary inspections of the job site. Print or Type 1. Name of Applicant Phone Number Address of Applicant b1 2. s[aaA 5&ixes &31-(4-7s- &ocD I gi &mm oy av G�a% Name of Contractor Phone Number Address of Contractor //-7 72 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4. 3eL &-&r,hed • 19 qy 161m 1v ta of 2(1 *t 6k Cy Work Description and Location(Street Number,Hamlet,Cross Str et) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. NOTE: All information requested by this S ature of Applicant Application/Permit Form is �' Required for a complete application! \� 2 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 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 No.: District 1000 , Section 1 Block 13 , Lot DV (o 7. Starting Date: pcs R Completion Date: 1 dal.) 8. Work Schedule: Phase Completion Date Excavation A CiC�► 1 Work Schedule Facility Installation _&q Must be provided Backfill&Completion maq l for consideration as a Pavement Replacement N-K h 4J0 t t 5 Complete Application. 9. Under which authority is application being made: OA. ie_ (L ' �Q tn4— See Town Code Chapter 237(E)-Provide Resolution by,or authority f m,l the e U�ty being modified. 10 Estimated Cost of Proposed Work: $ 11 Remarks: D 39 1 of 3 1 . Insurance Coverage:(AttacCop ) (a) Insurance Company: A- C-, �r�-'�L�Q,L h I S � (b) Policy#: L 2 Qo ( o a f �� J (c)State whether policy of certification on file with the Highway Department: Q (e (d)Coverage required extended to the Town: Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed: $1,000,000 per Occurrence and$2,000,000 general aggregate. 1 Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 1 Fees for Applications and permits: Basic Application Fee for Each Project Location - $500.00 ¢ 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. ! t /Service Connections excavations @$50.00 $ Sic o. 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 de th Total Lineal Footage of Excavation; L.F.@$30.00 $ D. Trench Excavations 5'in depth and over Total Lineal Footage of Excavation; L.F.@$50.00 $ E. 0 Utility Repair Excavations @$1,000.00/Each $ N n Additional Repairs of Same Service @$500.00/Each $ No. / C 0V TOTAI F. Official 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 Excavation permit to: in ac ordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)a ched reto. SUPERINTENDENT HI W TOWN OF SOUTHO ,N Vinc nt 4 01rFar do Z Date Date Received by the Town Clerkr(�_ Date Permit Issued V Permit No. 1 NOTE: Permit expires one(1)year from date of issuance. No work to start without 24 hour notice to Superintendent of Highways. Permit must be available at all times for inspection,on site,during construction. D 39 2 of 3 Copy Distribution: Permit# ( � Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 1 St 2nd 3rd 4t` (To Permit Clerk) REMARKS CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation U Unable to Measure(due to backfilling) B C Building Under Construction P Work In Progress D Improper Backfill(too high,not sufficient) Iff S Inspector Holding for Final Settlement of Excavation R Ready for Repair D-39 3 of 3 AM-- --- - -- - ----- L -i-U- H1 - I I ! I _ I LLL ----1 —L__I� Center Island) Services �— Sycamore Street 1 L-Patchogue,-N-Y 11772 1—I _Office: 631 -560,'0 —!�— —Fax: (631)1475-883010 I Contact:Sat-Cipolla Kell:-(631)1-7-74-85991 f J—L .I •I I Cablevision Projecf#:/7_h'� -77- 7-1 I I1 j I I - --I 130 l I I I -----�-__lam �—� U `o ►_3J--1' ' —� j�l ��_1 I; !_��l_ '_ L I s ® g THIRD PARTY CLAIM►Form Number. tike Referra� Flo) M DAMAGE N0" REFER TO: CONSTRUCTION ETS I Remedy Ticket: ®STX00138316437 Facll!ty/Dept: Riverhead (D$P Supervisor C.Greene Tech#/Cell#:F 2236 Luigi 516-779-1076 REASON FOR WORK 1: DAMAGE I REASON 2: CLI Pole: PS Amp Tap DESIGN INFO ONLY DESIGN I Design Type TYPE 1 2(R—Comm) Residential Existing/New Subscriber Existing Repair Location: j 1340 to 1440 Kimberly lane CORP 7839 Account.; 381940.02 Date. April 10,2021 Name: Nathan Willensky Phone 6311-766-8666 Gnd/Map Address: 1440 Kimberly X-Street. Nne Neck rd Town: Southold Hagstrom- �+,� X —" =s=_ talc .IDR ritttottt 3icalslo re eRi naeded Cor p Headend Node CH2 CH70 CH119 603 MHz 693 MHz 747 MHz X913112 Tap Pre-Fault Spliced Point:' Ground Block:; Tap Post-Fault aerialwarktRsY�wtenymbor(s)L - iTYPE .CABLE:REPLACEMENT igare3t(igirso n�l�li�i(s):;.�,.:,.._. I POLE HOUSE# _BozCover Neeys Rep)aEement= pedestals Is there a repair TEMP cable m lace at this time? YES Ftg: no Does the mquirea ROAD CUT? Ftg: t DRIVEWAY SHOT YES #OF DRIVEWAYS 2 CONSTRUCTION TYPE UNDERGROUND CABLE TYPE: - 625 FOOTAGE 100 feet Depth: 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 Fittings and equip.been changed?YES Comments: 'NO Is this a dangerous situation? 7_ _=-f_ 7•'__;;w 7.7 SIGNAL LEAKAGE MEASUREMENTS I C L.I Level @ 10 feet before repair meas L. van and repalr of leak Ifabove 2(luVim If leak is generated from plain Identify the approx.location of Home= ome Tap Drop Feetler Trunk the leak and document of Information on this forth. I C L.I.Level @ 10 feet after repair meas , Pad Value(d used) Dispatch V# --.DESIGN REFERRAL- -- - - _! All design referrals must have take off Doles and foots es Dravang must have exact location of cable dross and.feeder If needed Third Party Damage mforrnation Tech# Time worsted 100 feet of new U/G feeder needs to be ran from output lstrean of 10 tap by 1340 Kimberly to input of 7 tag)by 1440 2nd Tech Kimberly.7 tag)also needs new PED.PED is in between 1440 and 1410. 3rd Tech Fault is 18 feet from output of 10 tap. „ k t See pdsCh(ad (Construction Use Only) Tech(a)hComractor-assignedto ", gateassignbel. I NCR(not-coDstretated);'1 '_: - PCR=Given Back To; - NCR,Date,Give-'f Back, t ^";Aetual`Gomp Date: Tooh(s)/,C�rt:ractar!l:c completed the work,:,";_;" Cc%n�:eti Code- ' Construction Completion Comments: Needs Activation YIN NCR req.—comment