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Home My WebLink AboutJasmine Ln Town of Southold P.0 Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 09/01/26 Receipt#: 362849 Quantity Transactions Reference Subtotal 1 Excavation Permits 1879 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#1495 $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: 1879 Permit No. TOWN OF P.AFFOL't HIGHWAY DEPARTMENT ,�4 °y Peconic Lane 4 Peconic,New York 11958k (631)765-3140 'A , 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 Pennit"and"Special Conditions",if any and to permit authorized inspectors to make necessary inspections of the job site. Print of Type Nam of Applicant Phone Number Address of Applicant Sti3nem2. Na moAontrarctor / Address f Contr ctor I Name of PropeVy Owner Requesting Service(if applicable) Address of Owner p 4. �, -F� rOaA barI- LA nj(r Ja-SIi ;iJ e- Z✓l i Sa v��d 10( X�5'T� � ��G C� Work Description and Location(Street Number,Hamlet,Cross Street) r/ (a) Is construction located within 75 feet of tidal wetlands? *Yes N /� *If yes,other Town permits may be required. NOTE: All information requested by this ature of Applicant Sign Application/Permit Form is Z5- Z 4 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 Z 7. Starting Date: Completion Date: i 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 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 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 - $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. /Service Connections excavations @$50.00 $ 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 - $50.00 A Curb Cut would include any new or alteration of an existing driveway within the boundary of the right of way. The configuration of such is to the conditions set forth in Chapter 237 of town code. TOTAL$ 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 UT OLD,NEW YORK aniel J.Goodwin Fl;( 12c ' Date Date Received by the Town Clerk 7- 1 - 2 2-a 4 Q Date Permit Issued l r — Permit No.J (7 - ` 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: q Permit# $ I Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Insp6ction Date Findings (use code) Applicant Notified I 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 !Corp-House-Gust-Job# 107839-362716-04-L Region r rSuffolk —Market Type !Appointment ID l0783936271604L0815 Job No 11A !Job Type Trouble Call Technician Vendor ______IMastec North America Inc Customer First Name NTHONY !Customer Last Name jGOLDENSE ,Customer Type iR Customer Address 11300 JASMINE LN,Southold.NY 11971-3072 Latitude ---•--..—_._._____._. ..._.-,__.�__r__- _. .__....__... Longitude Customer Primary Phone Number Customer Seconds Phone Number —�-- �/ j6317658307 !Tech Number 2146 ech Name Kelly Blanc ppointment !Action Taken Time - 08-19-2026 10:47:32 1VorkTaskCode i 168 HSD All Out ff 1200 Diagnosis/Check Grnd Is This A Dangerous Situation jYes pprox. Footage Required (feet) 1100 Sprinkler System Yes [Is a driveway bore involved No _-__._-- --- - ---- lDoes the cable run in front of any other addresses Yes 'Levels at Bullet Vault-Channel 112 ,Have All Fittings & Equipment Been Changed Yes Is Temporary drop in Place: Yes Cable T e lls a road bore involved jYes If so,what addresses 11225 [Levels at House-Channel 10 Detailed Comments __ _ From across the street to the side of the house. jrs the customer WITHOUT service? f Levels at Tap=Channel �15 jFs there an in-ground wired dog fence?: ^ ,' 1FTTH Customer? r' 'Ali d ngo MUSt show I®Monca to nearest @@rn@po I@ng2 @f tr9noh, 9®ngth of•for® and eke of bdi polo. I H 13yo Boo oo �a r r / r - Pell. •