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Home My WebLink AboutOregon Ave Permit No. P� \ 1 V Y�'t`I VL JV V 111V.LJJ ��Pyct HIGHWAY DEPARTMENT .��~® Pecomc Lane b =� Peconic,New York 11958 (631)765-3140 , '�� 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 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or regulations 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 inspectors to matte necessary inspections of the job site. Print or Tyne 1. RCC, 0066&_"f(()R�_ G. raawIM6-VILA Name of Applicant Phone Number - Address of Applicant 2. Name of Contractor Phone Number Address of Contractor 3. kM U U LPl%1. 7-I L ,6 owesao Name of Property Owner Requesting Service(if applicable) Address of Owner 4.&0 0600 VbL CK14 Cft6Lk -Mr-_6-159 A-V_ i, 1� Gtr 0001 P6(-O (AIN Work Description and Location(Street Number,Hamlet,Cross Street) C (a) Is construction located within 75 feet of tidal wetlands? Yes No *If yes,other Town permits may be rcquircd. by dilb \\ JL�'lld6ULC U1 Hlllltll,[LLLL Application/Permit Form is I Required for a complete application! / 2b 18 Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the 1=-tin -Fall prnpnnecl...ca at:....n a ntl relat:..nshin t- public ftreeL nc cletaaell aero —:.^.,.�f all site and pavement restoration work. r V (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 Cleric. 6. Tax Map No.: District 1000 , Section Block Lot 7. Starting Date: Completion Date: 8. Work Schedule: Phase Completion hate Excavation Fork Schedule Facility installation Must be provided Backfill &Completion for consideration as a 9. Under which authority is application being made: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: 11. Remarks: D-39 1 of 3 12. insurance Coverage:(Attach Copy) (a) Insurance Company: (b) Policy#: (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extended to the Town: Any T.^..,.. ...r14Y1�,r Ro1'1 J -_ .+..... ........ .^.!' - ....0 t $ " the . ork ncrf�. cd: $1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. yv 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 7 /Service Connections excavations(a�$50.00 $ �(w No. 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 $ t„ T rCf[CR L'XCUVIddUffS f 8"Iff dCptn Lv 3'iff ucplfl 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 $ ,; T1al:ti.ne ,rz;�.....ati^„ ne1 nnnnn/Fuer; e No. Additional Repairs of Same Service @$500.00/Each $ No. TOTAL$ �� 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 accordan a with ou1,; ct tc+I,e llee tial Ccditicns"= "�„ .u1 Ccathticns"of P :+/.f i.l�±r� 1 A 1 .et0 SUPERIN NT WAY TOWN O SO D, YO Vine .Orlan o Date Received by the Town Clerk Date Q l �' �7 Date Permit Issued (L l J b ((9 Permit No. NOTE: Permit expires one(1)year from date of issuance. No work W siert wituvui 24 hour-nuf' e iv Superirriendeni of Highways. Permit must be available at all times for inspection,on site,during construction. D-39 2 of 3 Copy Distribution: Pea-mit# Highway Department Engineer(with page 3) Applicant i:;wic Cn.rk<<;ribiu«l) INSPECTORS RECORDS Inspection Date Findings (use code) Applicant Notified i st 2nd 3 rd 4th (To Permit Clerk) �*;i'vaH a�iti� IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due to backfilling) BUC Building Under Construction 11 DB Improper Backfill(too high,not sufficient) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 GENERAL C ONDMONS OF PEidMfd' APPI.ICATION/PERMIT FOR HIGHWAY EXCAVATION ANIS REPAIR 1. Perinittee's Contractors to Comply with Permit Requirements: The Permittee is responsible for informing its independent contractors, employees,agents and assigns of their responsibility to comply with this permit, including all special/site specific and general conditions imposed by the Highway Superintendent while acting as the permittee's agent with respect to the permitted activities, and such persons shall be required to comply with all permit requirements. 2. No Right to Trespass or Interfere with Private Property Rights: This permit does not convey to the permittee any right to trespass upon the lands of adjacent property owners in order to perform the permitted work nor does it authorize the impairment of anv rights,title.or interest in real or personal Dropertv held or vested in a person not a party to the permit. 3. Protection of the fflghway and Future highway Maintenance: If future operations or highway maintenance projects by the Town of Southold require an alteration in the position of the utility,structure or work herein authorized,or if,in the opinion of the Highway Superintendent the work performed under this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health, safety and/or welfare or vehicular or pedestrian traf ic,this permit shaii be revoked and the utility, structure,fill, excavation, or other modification of the highway hereby authorized shall not be completed. Additionally,the permit may be revoked if the Highway Superintendent finds that the issuance of the permit was illegal or unauthorized or that the applicant failed to comply with any of the terms and conditions of the permit or Chapter 237 of the Town Code. 4. Reyuca6un of the Ferinii by idle n:J4,1.119yay 311PCr1nLC1141MIL.-. 11 LUC I11bllWay 3UP01711ILCULL IIL UCC1I15 1L necessary to revoke this permit and the project hereby authorized has not been completed, the applicant shall,without expense to the Town and to such extent and in such time and manner as the Superintendent may require,remove all or any portion of the uncompleted utility, structure or fill and restore the site to its former condition. J. 1\ULl�.G Ul eiiu`caiCcii.Lc11L. iii.iUaai/.=i uuiub piivi LV U1 LIM,PlUJUL L, L11L,IJLd11LLLLLU[L11W Vl contractor shall notify the Town Highway Department in writing that they are fully aware of and understand all terms and project conditions of this permit. Upon completion of the work,the contractor shall provide photographs of the completed work to the Town Highway Department and request a Final inspection. V. Utm-2-mV Vl LyYl�l Wall1.tib L�1LLbV1141J. 111V JLVIKSV Vl VVL1J LL tLV LI Vll V1111111111V4L LLL1W V1 L111LV1141J JLLLLll VV confined within the project work area and/or adjacent areas where permission/legal access has been obtained in a manner that does not interfere with normal highway traffic. 7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility mark-outs and shall take all precautions to protect same. Damage to existing utilities shall be the 8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town Board prior to closing a road. Temporaiy lane closures may be permitted with the approval of the Highway Superintendent. This item will included but not be limited to the installation of appropriate signage and flag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen r�� .... . .^.�: ... ... . .. �. . .. and/or expedited restoration of the Work Zone. 9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job site on a daily basis. All stockpiled soil as well as all other pre j ect materials that will be staged within the Right-of Way must be delineated with reflective signage or other means to meet the minimum requirements YY ' I ' i I , 1 -Poi D bf - - -- - - - - - - - - - - 3OL41 C� - 60yu oo -56 4® POLL r - - - - - - Cc..rCWbic <i� - -- - - , I I �