Revised 02/22/2017 Page 2 of 2
APPLICATION FOR EXCAVATION / GRADING PERMIT
• Outlines of all existing and proposed structures, driveways, walkways, impervious surfaces to be located on property.
• Location of all existing storm drainage structures, soil erosion and sediment control measures and utility facilities
including electric, water, telephone and cable television which are located within the property lines.
• Plan to include existing and proposed contours according to the U.S. Geodetic Survey Datum at intervals not to exceed
two (2) feet. Existing contours are to be indicated by dotted lines, proposed contours to be indicated by solid lines.
• The location of all significant natural features such as water courses, depressions, ponds, marshes, and other wetlands,
whether or not officially mapped.
• Final Sealed Topographical survey to be submitted at completion of the project
• All existing vegetation (trees, brush, grass/lawn areas, landscaping) disturbed during the project shall be maintained and
corrected if damaged.
• Application must be filed out completely
• If contractor is applicant, the contractor MUST provide consent from the homeowner authorizing him to file for the
• Proof of Insurance – The applicant shall file with the City of Glen Cove a Certificate of Insurance indicating that the
City has been named primary insured under an insurance policy in the amounts of ($300,000 / $500,000) for bodily
injury and ($50,000) for property.
• Worker Compensation – Proof of insurance must be submitted from the contractor and/or homeowner at the time of
submission. (form C-105.2)
IMPORTANT NOTICES: PLEASE READ & SIGN
The applicant hereby agrees to hold the City of Glen Cove harmless on account of damages of any kind which may arise
during the progress of the work authorized by this permit.
The applicant certifies all persons concerned with actual work under this permit are duly covered by Workman’s
Compensation Insurance and the City shall be harmless on account thereof.
Work under this permit shall commence within thirty (30) days of the date of this permit and shall be continued in an
The City shall have the right to select counsel to represent it for the defense of any claim, suit, or action arising hereunder,
all fees and disbursement for the same to be paid by the applicant herein.
The applicant shall be responsible for all damages caused to public utilities and shall replace any cracked or damaged sewer
or water mains with new pipe.
The applicant shall take every reasonable precaution to properly warn all persons of any danger during the course of the
The permit does not include any privileges of encroachment in, over, or under, or upon any city street or right-of-way.
In consideration of being granted this permit, the undersigned applicant accepts it subject to the conditions described.
I, __________________________________, the above-named applicant, hereby attest that I am the lawful owner of the
property described within or am the lawful Contractor/Agent of said Owner and affirm under the penalty of perjury that
all statements made by me on this application are true.
Signature: _________________________________________________ Date: _______________________
(SIGNATURE OWNER / CONTRACTOR-AGENT)