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Home My WebLink AboutHighway Permit - Street LightSegion 10 Office: NEW YORK STATE DEPARTMENT OF TRANSPORTATION Suffolk State Office Building Veterans Memorial Highway, Hauppeuge, New York Sheet ~_ of. / Re: ~_~ ~r111- ~o~_ Gentlemen: The site plans for the above noted project have been reviewed by this office. Please be advised that before a Highway Permit can be issued at this location the item(s) checked below must be forwarded to the Permit Department. Sincerely yours, Harry R. T y erg Regional Permit Engineer HRT: I~ Check or money order to the State of New York for $ Bond (sample enclosed) for $ Three copies of revised prints showing /plicaHon is hereby mode for o hlghwoy work permit TOWN OF SOUTHOLD 425 Main Street Greenport, New York 1. Reguested duration from 19 thru 2o Protective liability Insurance covered by Policy No° 3. Workmen's Compensation Insurance Policy No. ~. Disability Benefits Coverage Policy No. STr,~)F NEW YORK-DE PARTMENT OF TRANSPORT, HIGHg~I]I~I~wORK PERMIT APPLICATION FOR UTILIT l-ENTER NAME AND · ~ MAILING ADDRESS 11944 L~N THIS SPACE Highway Permit No. Effective Date BOND: Waived Municipality 19 , to apply to the operation(s) checked below. ; expires on 19 expiring Check Type of Operation PERMIT FEE Additional Fee Base Indicate No] Times Fee Ft./poles Unlt Rate $10 .10 per ft. Sub. Total Show Ins. Fee Total Amt. Amt. ar PERM- of Fee (v') if 17 or Under- and/or Permit taking an file Ins'urance Charged 2.50 PREPARE 3 COPIES Amt. and/or Bond ~ b. Underground private service sub-surface connection NC NC ~ c. Overhead $10 .50 per unit Erec ng poles towers, etc. ~ d. Overhead $ o :: s~o %~. Overhead NC ~ (]) Regular installation $10 ~ (2) Requiring structura~ changes (Existing $]00 Telephone Booths $25 $10 $25 $10 ~ b. Annual Inctudes tree work and other work permitted as single jabs. (Department must be notified each time worh is to be performed,) $500 _~ c_.Z Private repair__of w.~ate,__or s.~ewe_.~r lin__es -- - N._.[_C -- -- -- .~ a. Relocotlan - D.o.T. requested NC $500 NC -~b. Commerclol service sub.surface connection $10 .10 per ft. ~ Co Commercial service overhead connection NC NC ~ d. private service su~-surface ~ -- NC TOTAL PAID 2.50 Wo~ ~0~ b. described ~rleB~ 0, fona~s: TO install and maintain street lighting fixtures on Route 25 within the limits of and on behalf of the Town of SOUTHOLD. ~] Addlt~anal work descr~ptlon is attached; [] Plans pag~s2o~/o,,j:~,l_l~:~~ [~l~l~(.~sj, file~3~0ing work to be performed at: LOCATION ( ~ ~ ~ ) State Highway No. I ~t ..... tation and slotion in t~. To.. o~ SOu~old County o~ Suffolk PERM 32 & 3~(12/70} REVERSE r-SPONSIBILITIES OF PERMITTEE 1. PROTECTIVE LIABILITY INSURANCE COVERAGE ' :' ' ' ..... ' Permiftee must_hgve pr.ote.ctive Jiability insurance coverage in accordance with DepeJ',tment~equi~r~Cents; (See Infor- mation on Protective LiabiJity Insurance Required for Highway Wor~,?~(rnits a_nd/mt Spec.iai I~uling;.Permits, Form PERM-27):~_~ ~ _:: Expiration of, or lack of, liability insurance automatically terminates the permit. Insurance coverage may be provided by furnishing the Department with one of the roi Jawing: a. A Certificate of Protective Liability Insurance for Permits on State Highways (Form PERM 17, NYSDoT). b. A $2.50 remittance (check drawn on a New York State Bank or Certified) for coverage under the Departmental Blanket Policy. c. An Undertaking may be fur'mshed by Public Service Corporations and Government Units only and must include the wording required by the Department. 2. COMPENSATION INSURANCE AND DISABILITY COVERAGE The applicant is required to have compensation insurance and disabiJity coverage as noted in the provisions of the Workmen's Compensat.,iog.J_,ew and Acts amendatory thereof for the entire period of the permit, or the permit is invalid. 3. NOTIFICATIONS Notify Commissioner, through RegionaJ Office, one week prior to commencing work, except emergency work by public service utilities which shouJd be reported the next work day. Work must start within 30 days from dote of permit. Notify area gas distributors 72 hours prior to any blasting. Notify Utility Companies with faclJities in work area (permission must be obtained before doing work affecting utiJities' facilities) before starting work. Notify land owners of abutting lands, before disturbing trees. Notify Department of Transportation et concJusion of work and return original copy of permit to Regional Office. Annual Maintenance Permit Notifications: Notify by telephone the District or Resident Office, one week in advance, each time regular maintenance work is to be performed. In emergencies, notification by telephone shouJd be made the next work da);. 4. SITE CARE AND RESTORATION An Undertaking, a bond or certified check in an amount designated by the DepartmentofTransportation may berequired by theRegionaJ Office, before a permit is issued, to guarantee restoration of the site to its originaJ condition. Jf the Department is obJiged to restore the site of its originaJ condition, the costs to the Department will be deducted from the amount of the permittee's guarantee deposit at the conclusion of the work. The permittee is responsible for traffic protection and maintenance, including adequate use of signs and barriers during work and evening hours. No unnecessary obstruction is to be left on the pavement or the right of way or in such a position as to block warning signs during or between work hours. No work shah be done to obstruct drainage or divert creeks, water courses or sJuices onto the right of way. All faJsework must be removed and all excavations must be filJed in and restored to the satisfaction of the Regional Traffic Engineer. 5. COSTS INCURRED BY ISSUANCE OF THIS PERMIT AIl costs beyand the limits of the protective liability insurance, surety deposits, etc., are the responsibility of the permittee. The State shall be beJd free of any casts incurred by the issuance of this permit, direct or indirect. 6. SUBMITTING WORK PLANS The applicant will submit work plans and/or a map as required by the Department. This shall include such details os measurements of driveways with reJation to nearest corner, positions of guys supporting poles and o schedule of the numbec of poJes and feet of excavation necessary for compJetion of the work on the State right of way. A description of the proposed method of construction will be incJuded. PJan work w[th future adjustments in mind, as any relocation, repJacement or removal of the instolJation authorized by this permit and made necessary by future highway maintenance~ reconstruction or new construction, wiJJ be the respon- sibility of the permittee. The permittee must coordinate his work with any state construction being conducted. 7. TRAFFIC MAINTENANCE Traffic shall be maintained by the permlttee on the highway, in a safe manner, during work and evening hours until its finoJ c. ompJetion. Suitable safeguards, to reduce conditions dangerous to fife, limb and property to a minimum, must be provided by the perm.ittee~ (in, fucking flc~gmen when requested by the Department) - ~ If,-i'nCthe accbums ko'pt by'he {~epa~m-'ent,'co~s of ~u~er~io~'~r~ ~o~nd foL~e e~ce~c~in~gJy ~igh?t~'e'Deparfment re- serves the right to bill the permittee for actuoJ expenses incurred by the supervision and inspection of the permittee's 9. SCOPE .... ~ . a. ~,reas Covered . . ~ ~, _~ :'~:' )' Permits issued are for highways, bridges and cuJverts o~,er which the New York State Department of Transportation has jurisdiction. (Local governments issue permits for their own jurisdiction.) b. Legal The privilege granted by the permit does not authorize any infringement of federal, state or local laws or regulations, is limited to the extent of the authority of this Department in the premises and is transferable and assignable only with the written consent of the Commissioner <~fTransportation. TheCommissioner of Transportation reserves the right to modify fees and to revoke or annuJ the permit at any time, at his discretion without a hearing or the necessity of showing cause. d. Locations Work locations must meet approval of the Department. (Additional oaaes to this al~l~Jication vary accordina to the purl)asa and type of work to be permitted)