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Beulah Ave Town of Southold P.O Box 1179 Southold, NY 119.71 * * * RECEIPT * * * Date: 08/14/26 Receipt#: 362284 Quantity Transactions Reference Subtotal 1 Excavation Permits 1876 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#1486 $550.00 23 Montrose Corp., DBA AR Underground Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: 23 Montrose Corp., DBA AR Underground 21 Greg Lane East Northport, NY 11731 Clerk ID: JENNIFER Internal ID: 1876 Pe2mit No: I �Q TOWN OF SOUTHOLD HIGHWAY DEPARTMENT ram„ Peconic Lane � 4 � Peconic,New York 11958 (631)765-3140 ,off �f 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 make necessary inspections of the job site. Print or Tune 1. ;01 W Name of pplicant Phone Number Address of Applicant 2. a e Co r cosh A 2J G — o r Q Name of Contractor Phone Number �( Address of Contracto 3. Ifn Ve, ( ±Name of-Prop'/ edty Owner Requesting Service(if applicable) A ress of Owner 4. J -f � A A J - reA�h"` CdJo3 Are, .3 I-Pk rc l bore— (Ank r �l /1/-,? /0 Work Description and Location(Street Number,Hamlet,Cross Street) (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 Signature of Applicant Application/Permit Form is 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 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 Block Lot 7. Starting Date: Completion Date: 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. 9. Under which authority is application being made: IA W1 See Town Code Chapter 237(E)-Provide Resolution b ,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work:, $ 11. Remarks: Pi - ro no co m D-39 1 of 3 12. Ingurance Coverage:(Attach Copy) Q r I„ 6Y Insurance Company: l� ►'l (b) Policy#: ' (c)State whether policy of certification on file with the Highway Department: (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$2,000,000 general aggregate. 13. Security: ) (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Road Opening Applications and permits: Basic Application Fee for Each Project Location -A Project Location would include each Bell Hole and/or every road opening KEi n)within any 50'Radius whether or not they maybe 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 $ S� 1No. 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 depth 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. Utility Repair Excavations @$1,000.00/Each $ No. Additional Repairs of Same Service @$500.00/Each $ No. F. Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. 15. Fees for New or Alteration to Curb Cut: Basic Application Fee - $50.00 A Curb Cut would include any new or alteration of an existing driveway within the boundary of the right of way. The configuration of such is to the conditions set forth in Chapter 237 of town code. TOTAL$ 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 and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto. SUPERINTENDENT OF HIGHWAYS TOVRq 9F SOUTHOLD,NEW YORK aniel J.Goodwin ff/ 3 eC Date Received by the Town Clerk � Date Date Permit Issued g I Z�Permit No. 18 r7 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 o r Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Insp6ction Date Findings (use code) Applicant Notified 1 St 2nd 3rd 4th (To Permit Clerk) REMARKS CODE IB Improper Barricades 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 for Repair D-39 3 of 3 Cd Myr • . E" 3� ` S 0 �p tjo � .31 ff Construction Referral DSTX: 00230459282 Associated Ticket#(UTT OR DSTX): PRG Claim#: 220434 Region LIE Construction Corp 7839 Account# Node# X913103 Date 5/2/2026 Address 320 MOUNT BEULAH Amp# LE-20 Supervisor LUIGI Town SOUTHOLD Rolt# Tech 2224 X-Street OLD NORTH RD Cell# Phone# (516)369-40' Priority E.MERrGJENZYN Immediate need for repair,Standby call out,Offline customers&cannottemp,Emergency work completed but referral needed. Priority:1 Safety Hazards,Customer impacting,CECR,AFECs,Complaints,Temps on the ground. Priority:2 Safetemps,Aerialtemps,Lashing,Low feeder that isn't a safety issue orimmediatelyneeded. P-2 Priority:3` Broken PEDs,Broken Dog House,Lockbox replacements that are non-safety issues. Priority.4 Non-service impairing CLI leaks,all other project types. Referral Info Cut Cable •! NO Underground mom • .- NO HFC 500 FT NO ... YES ....- .e• •w Safe 3 Under Road E -• ©" o a • • o o --••• • - PLEASE REPLACE 500 FT UG 700P3 FROM RISER POLE-37/LE-20 TO INPUT OF TERM TAP IN FRONT OF 320 MOUNT BEULAH. CABLE AND CONDUIT CUT UNDER ROAC Third Party Damage Information PRG Claim? Yes PRG# 1 800-259-8753 ember of OSP Teehs 1 Reg Hrs 4 OT Hrs DT Hrs Misc 220434 I . Company WATER DEPARTMENT Comments UG HFC CABLE CUT BY WATER DEPARTMENT AT THE CORNER OF MT BEULP Address 320 MOUTH BEULAH AND OLD NORTH RD. Phone# N/A 1