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Home My WebLink AboutKerwin Blvd Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 08/14/26 Receipt#: 362282 Quantity Transactions Reference Subtotal 1 Excavation Permits 1875 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#1485 $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: 1875 Permit No. ! 3 /S TOWN OF SOUTHOLD � �>5� ��;�� HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958ky (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 make necessary inspections of the job site. Print or Type Name of Applicant Phone Number Address of A plicant 2. �3 M0Ym�� LCt r u 0 �Pv' - a 1 �'� L� -JV ✓-�'� v/�' Name of Contractor V r�Phone Number Mdress of Contractor 3. e d�(p� `�- �J flit/ �1 V Cif G��✓J�v/ Name of Property Owner _Requesting Service(if applicable) Address of Owner I 4. C 7 ►CM( �` `f `^�-Yl �u�-1 �D Yjo V _ Work Description and Location(Street Number,Hamlet,Cross Street) "�lfl`l P6 .— >CT'rP C (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 pplicant Application/Permit Form is Required for a complete application! ate 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: See Town Code Chapter 237(E)-Provide Resolutiqby, r authority om,the Utility being modified. 10. Estimated Cost of Proposed Work: $ 11. Remarks: ry) N G C) 'its -31 — C-51 e7' D-39 1 of 3 12.. Insurance Coverage: (Attach Copy) (a) Insurance Company: �(3 �� C C (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 pen-nits: Basic Application Fee for Each Project Location - $ 000.00 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. /Service Connections excavations @$50.00 $ J� 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 $ 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 - $50.00 A Curb Cut would include any new or alteration of an existing driveway within the boundary of the right of way. The configuration of such is to the conditions set forth in Chapter 237 of town code. TOTAL$ 50 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 TOWN OF THOLD,NEW YORK r- Daniet J. Goodwin n Date Date Received by the Town Clerk �1 �_�/ Zb Date Permit Issued �' �I 2G Permit No. 18 / S 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 a�all times for inspection,on site,during construction. D-39 2 of 3 Copy Distribution: Permit# I S Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1st 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 - J��l11 1RlIAI 31 ' qk IA 4 " � i 1L.L11.l.a_H Keterrai type - u,IE ncKer uroa«w• Subs Affected 10 Dangerous Situation NO ' Sevice affected Refer To Construction Temp In Place YES Facility Riverhead Corp 7839 Account# Node X9A105 Date 8/1912025 Sub Address 2495 KERWIN BLVD Amp# Supervisor_ Luigi Tiberia Town SOUTHOLD ROIt# Phone# (516)779-1076 X-Street BAYSHORE ROAD Cell# Tech 2226 Location of Fault PS ID: Phone# 516-807-4869 Priority:1 NEED TO REPLACE 150FT OF 650 UG FEEDER FROM OUTPUT OF 17 TAP ACROSS THE STREET TO INPUT OF 14 TAP. Priority:2 HAD TO RUN RG11 TEMP IN TREES.FAULT IS INROAD AN HAVE A CLI LEAK.CABLE WAS CAUSING ERRORS. Priority:3 Priority:4 HFC EMMMMM Damaged Cable UG 650 MC2 Feeder Replacement YES 15OFT :. Fault 1 Footage Fault 2 Footage NO E Fault 1 location Fault Repairable? Aeeessible Fault 2location Fends AC How many Amps Water Migration Temp Footage Temp Exact Point to Point Location [Detailed FTTH' -oe o - Fault Repairable E Aeeessible Sidowalk Curb RoadlParkin lot Fibers Rolled Tubes Available Fibers Available 103IMSHROMMIM Third Party'Inform 4tIon Claim# PRG# 1 800-259-8753 Tech 1 Reg Hrs OT Hrs DT Hrs Misc Tech 2 Reg Hrs OT Hrs DT Hrs Misc Entry Splice Shrink Company Comments Address Phone#