Fillable Highway Work Permit PDF (Town of Brookhaven)

Fill Online, Printable, Fillable, Blank Highway Work Permit PDF (Town of Brookhaven) Form

Use Fill to complete blank online TOWN OF BROOKHAVEN (NY) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Highway Work Permit PDF (Town of Brookhaven)

On average this form takes 4 minutes to complete

The Highway Work Permit PDF (Town of Brookhaven) form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Highway Engineering
1 Independence Hill, Farmingville, NY 11738
Phone (631) 451-9090 Fax (631) 716-0572 www.brookhavenny.gov
Daniel P. Losquadro
Superintendent of Highways
5/23/18
HW-11
INSTRUCTIONS FOR COMPLETING HIGHWAY WORK PERMIT APPLICATION FORM
1. The
SCTM (Suffolk County Tax Map) number can be found on the property tax bill. This number can also be obtained by
calling the Assessor’s Office at 631-451-6300 with the property owner’s name and the property address.
2. The
applicant’s name may be the property owner, contractor or utility company name. The applicant’s name and address
will be used for all correspondence.
3. Gi
ve a brief description of proposed work.
a) Planning Board Number is required for new residential construction.
b) Site Plan Log Number is required for APPROVED site plans.
c) A full size, legible copy of survey MUST accompany the completed application for existing dwellings.
Draw directly on the survey where you plan to do the work, and what you plan to do.
d) Utility companies must provide a sketch of the work area, including distance from nearest cross street.
Also include job reference number.
e) Land Divisions – Map, Planning Board and Zoning Board Approvals, and any mitigation measures are required.
f) Road Extensions – 2 copies of Plan and Profile required.
4. $150.0
0 FEE, payable by check, bank check or money order MUST accompany application to initiate the permit process.
There is a $75.00 fee for returned checks. Credit cards are accepted. A service charge will be applied to each transaction.
We cannot accept cash. Applicant will be notified if additional fees are required. The additional fees are to be paid when the
permit is issued.
5. Insurance Requirements: The Permit Holder/Contractor must furnish the Town of Brookhaven with a Landlord’s & Owner’s
policy or Homeowner’s Liability policy naming the Town of Brookhaven and Superintendent of Highways as ADDITIONAL
INSURED in the following amounts: $100,000.00 and $300,000.00 personal injury and $50,000.00 property damage.
If the Permit Holder/Contractor already has liability insurance, a certificate naming the Town of Brookhaven and
Superintendent of Highways as ADDITIONAL INSURED for the same amounts is required.
If you are using the contractor’s insurance, the contractor must provide the above certificate of insurance and a letter on
company letterhead, authorizing the applicant/property owner to use the contractor’s insurance. We must have the
original letter. This letter cannot be faxed or emailed.
6. Bo
nding Requirements (if applicable): Applicant will be notified of any bonding requirements and options prior to the
permit being issued.
7. Che
ck that the application has been completed and signed, and all the required items are attached.
It is important that you read the Conditions and Restrictions BEFORE signing the application.
** CA
LL BEFORE YOU DIG ** ONE- CALL CENTER 1- 800- 272- 4480 **
APPLICATION WILL NOT BE ACCEPTED WITHOUT THE PROPER DOCUMENTATION AND FEE
AP
PLICATIONS CANNOT BE FAXED OR EMAILED
Town of Brookhaven
Highway Department
Highway Engineering
1 Independence Hill, Farmingville, NY 11738
Phone (631) 451-9090 Fax (631) 716-0572 www.brookhavenny.gov
Daniel P. Losquadro
Superintendent of Highways
5/23/18
HW-11
APPLICATION FOR A HIGHWAY WORK PERMIT
Application is hereby made for a Highway Work Permit on or across a road known as _________________________________________
in
the hamlet of ________________________, Town of Brookhaven, in the County of Suffolk, State of New York.
SCTM # ______________________________ Planning Board # ____________________ Site Plan # _______________________
Section Block Lot
Name & Address of Applicant ___________________________________________________________________________________
Print name Street City State Zip
Ph
one # ___________________________ Cell # ___________________________ Fax # ____________________________
Brief description of proposed work :_______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CONDITIONS AND RESTRICTIONS
• The
work authorized by the permit, when issued, shall be performed to the satisfaction of the Superintendent of Highways
or his designated representative.
• The said applicant hereby agrees to hold the Town harmless for any type of damage that may arise during the progress of
the work authorized by the work permit or by reason thereof.
• The Superintendent of Highways reserves the right to, at any time, revoke or annul the work permit should the said
applicant fail to comply with the terms and conditions upon which it is granted.
• Wheel Cutter or Pneumatic Hammer Asphalt Cutter to be used before trenching and before paving.
• The work permit covers work done in the area of the Town right-of-way, up to the property line.
• Traffic shall be maintained by the applicant on this section of highway while the work is in progress and until its final
completion. Proper barricades and flares must be maintained for protection of persons and property, and road restored to
its original condition.
• TOPSOIL AND SEED MUST BE APPLIED TO ALL SHOULDER AREAS.
• 5" pavement on all road trench areas and patched immediately after installation. Seal-coating where necessary.
• If and when necessary, Brookhaven Town Highway Department will, on matters of emergency or complaint, take steps to
repave trenches on charge-back basis to the above applicant. The applicant is responsible for paying all necessary expenses
incident to supervision and inspection by reason of the granting of such permit, as certified by the Superintendent of
Highways. Such payment to be made within 10 days from the rendering of the certified account.
** CALL BEFORE YOU DIG ** ONE- CALL CENTER 1- 800- 272- 4480 ** CALL BEFORE YOU DIG **
APPROVAL OF THE REQUESTED HIGHWAY WORK PERMIT SUBJECTS THE PERMIT HOLDER TO THE RESTRICTIONS,
REGULATIONS, AND OBLIGATIONS STATED ON THIS APPLICATION AND ON THE HIGHWAY WORK PERMIT.
Applicant’s Signature ______________________________________ Date ___________________
Town of Brookhaven
Highway Department
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Highway Work Permit PDF (Town of Brookhaven)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document