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Home My WebLink About4630 Youngs Ave Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 09/06/19 Receipt#: 259917 Quantity Transactions Reference Subtotal 1 Excavation Permits 1354 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#5023 $550.00 Joe's, Underground Utilities Inc. Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Joe's, Underground Utilities Inc. 8 Gull Dip Road Ridge, NY 11961 Clerk ID: LYNDAR Internal ID• 1354 f � ry PennitNo.-13,c), q R€CENED TOWN OF SOUTHOLDg�EfOj,�� HIGHWAY DEPARTMENT _ 6 209y: Peconic Lane SEP Peconic,New York 11958 o �" (631)765-3140 Southold Town Clerk 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 1. (R-ob-5on 631 851Z oip Name of ApplicantPhone Number Address of Applicant Jcacs L) r9rovnd. UA-C I0-ccs sive 2. RZdb1�o,r, ` 63r-yS'q- aS) Z 19 &v(I D10 P.1 -t(?tClye. 1,J y 119 &/ Name of Contractor Phone Number Address of Contractor 3. ,VOyat 9 S Name of Property Owner Requesting Service(if applicable) Address of OwRdr 4. 1-e p l��e%,sl�l! ec.�� l��e i/�'/a ��/` 3v Uo�v► s esu e -under 2 .41 „�j�Yy �e.�- P� /7C�Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No C� *If yes,other Town permits may be required. NOTE: All information requested by this Signature of Applicant Application/Permit Form is .0 Required for a complete application! 9- 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 55 , Block Lot I 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 Res6lution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ L 11. Remarks: t n 5 )'✓l/ l Irr0- �r Cad c1151 o, urldor rU �'rode Id A CAU-se- D-39 1 of 3 12. Insurance Coverage:(Attach'Copy) (a) Insurance Company: AA r6vi 15s /a (b) Policy#. 3 a!62 33 ZG 64/0 30000 6 Ll 2 uOO (c)State whether policy of certification on file with the Highway Department: e5 (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 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 $ --y 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. TOTAL$ SS"Tj ,OU F Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. * * * * * * * * * * * * * * Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavati n permit to: in ccordance wi this application and subject to the"General Conditions"and"Special Conditions"of permit(if an attached here SUPERINTENDE T S TOWN OF SOU O E RK Vi cent .Orlando Date Date Received by the Town Clerk cl -(4ai 1 Date Permit Issued `—(o —) Permit No. 13 5 c4 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 f � Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1 St 2nd 3rd 4 t (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 r GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Permittee's Contractors to Comply with Permit Requirements: The Permittee is responsible for informing its independent contractors,employees,agents and assigns of their responsibility to comply with this permit,including all special/site specific and general conditions imposed by the Highway Superintendent while acting as the permittee's agent with respect to the permitted activities,and such persons shall be required to comply with all permit requirements. 2. No Right to Trespass or Interfere with Private Property Rights: This permit does not convey to the permittee any right to trespass upon the lands of adjacent property owners in order to perform the permitted work nor does it authorize the impairment of any rights,title,or interest in real or personal property held or vested in a person not a party to the permit. 3. Protection of the Highway and Future Highway Maintenance: If future operations or highway maintenance projects by the Town of Southold require an alteration in the position of the utility,structure or work herein authorized,or if, in the opinion of the Highway Superintendent the work performed under this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health, safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility, structure,fill,excavation,or other modification of the highway hereby authorized shall not be completed. Additionally,the permit may be revoked if the Highway Superintendent finds that the issuance of the permit was illegal or unauthorized or that the applicant failed to comply with any of the terms and conditions of the permit or Chapter 237 of the Town Code. 4. Revocation of the Permit by the Highway Superintendent: If the Highway Superintendent deems it necessary to revoke this permit and the project hereby authorized has not been completed,the applicant shall,without expense to the Town and to such extent and in such time and manner as the Superintendent may require,remove all or any portion of the uncompleted utility,structure or fill and restore the site to its former condition. 5. Notice of Commencement: At least 24 hours prior to commencement of the project,the permittee and/or contractor shall notify the Town Highway Department in writing that they are fully aware of and understand all terms and project conditions of this permit. Upon completion of the work,the contractor shall provide photographs of the completed work to the Town Highway Department and request a Final inspection. 6. Storage of Equipment c&Materials: The storage of construction equipment and/or materials shall be confined within the project work area and/or adjacent areas where permission/legal access has been obtained in a manner that does not interfere with normal highway traffic. 7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility mark-outs and shall take all precautions to protect same. Damage to existing utilities shall be the responsibility of the contractor and shall be repaired at the contractor's expense. 8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town Board prior to closing a road. Temporary lane closures may be permitted with the approval of the Highway ,Superintendent. This item will included but not be limited to the installation of appropriate signage and flag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen emergencies require immediate notification of the Highway Department and shall be limited to immediate and/or expedited restoration of the Work Zone. 9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job site on a daily basis. All stockpiled soil as well as all other project materials that will be staged within the Right-of Way must be delineated with reflective signage or other means to meet the minimum requirements of the NYS DOT Construction Standards. ��•' 1�7 Arm ��-`"�•�� - V' JF &'C)ao( 2,3, \� C/s odd N°,,,�L �d v s , a �� roc c�i�-`f H vCU I l C. 1 b v\ May 01.1s11:36a Bay Harbour = 6312892176 P.2 DATE(MUMM Y0 AC409 CERTIFICATE OF LIABILITY iNSURANCE aero �2o�s r TIFiCATEISISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THECERTIFICATEHOLDER.THISATE DOES NOT APFIRMATIVMY ORHEGA'IWELY AMEND=EXTEND OR ALTA-R THE COVERAGE AFFORDED ByTHEPOMES THIS CERMCATEOFINSURANCE DOES NOTCONSTITUTE A CONTRACTSET@IiEEN THEiSSUING INSURER(SL)AUTHORIZED ENTAIM OR PRODUCER,AND THE CERTIFICATE HOLDER. IAIPORTAN7 Uthe CerNflcate holder lSS an ADDITIONAL INSURED=the IIDlk;3 104 mush ADDMONAt INSURED provisions Orbe endonaed. IM 8 ORrAN '.Wt t8 WAIVED,subject to the teerrs and conditions Ofthe policy,certain polities may requirean endorsement A statement on this eoipte does not confer fights to the certificate holder in lieu of such endoorsemen s CORMT me John C Barry Bay Harbour ins Agency,Inc. PHONEut 758-1550 FAX"° sst � �- Ji,anvr�gavharboucaroua.corn 88 Watrmriy A"flue NAIcn Patchogue,NY 11772 IN SUR AFFCADINGCOUERAGE MMIMRA: EVSnSMn Insuraac� - u IHSU R9: urance�►mertcan i trtnce 49218 Joos Underground Willies Inc wSUPRERC. 8 GUIs Dip Road INSURERD: Ridge.NY 11961 1148UREM COVERAGES CERTIFICATE NUMBER: 00000000.307851 REVISION NUMBER: 2 THiS ISTO CERTIFY THAT THE PCUCIES OF iNSURANCE USTED ocLC ry W4.-BBE".+'j W-vED-1O THE INSUREDNAMED ABOVE=OR THE POUC`!PERIOD INDICATED.NOTWITHSTANDING ANY REQUIRS11AEN',TERM OR CONDITION OFANYCONTRACT OR OTHER DOCUMENT'NTH RESPECTTC WAICHTHiS CERTiFiCA'E Tiny BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY-HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS. EXCLUSONSANDCONDITIONSOF86C=POLE IES UMrfSSHCWNMA`sHAVE BEEN REDS�PAID a FJ�- � TYP6CFINSURANt NU fun MMMAntm A' X wweEaraALGENERAL IJABILITY : Y iN 13EQ3326 j,f=019 04t291zo20 eaclrocarfMF4f E s 1000000 S 10,000 CANS40DE 7 ccwzt I MED EXP M are soul s S 000 ZERSONAL&ACdWURY $ Z00%000 GENERA-AGMEATE 00.000 TLAr44WGA-fEuu1TAPPUESPER: d A Mn — JECTI PwRor (!lJ► W4Q0UGs-Gwir�O ?AW PO= lJx S o - y aurouoaaeuAeum eJCILYttylWYtPerP�i b AWMM ovamo SCHEOULED BODILY RQMjPera=dMd)1 S AUMS ONLY AUTOSGE i AAUUIO ONLY AUTOSONLY 3 I g urrermLALms X -AtofNPLDYEiL�tlA8rL11Y OCCUR t ELD30000649000 0aJ2912019 aa12912020 EACG�Y TRR�ICE S 5�OOO,a00 E4LtAB ¢Att,l.S-tdADE � i S i O® MS �1— OTH- Yep�g�NPEFL7ATtON YfN EI A. EACH 3 0ANY PROPRIES ?EXECtiT1VE �"I tilA L J EL>kSEASE-EAE4d3tOlt1 S {Martlti4my fn I�tI) hy�resGt7Bu3tet E.L.DISEASE-POUCYtIMR 3 OESCR C ERAT below nd:eerrvua� iroarr`u-iwin w--..�...-._.._.L�AYt4M11a!VEHICLES tACDRD ia7,AddYlotpl WatnatksSChcdule,rtmy bBalmehed Fi teOtesWae itt requhetll CerIftate Holder is included as additional insured as per written contraCL RepaalrMpim CATV lines for Cablevislon. CERTIFICATE MLIDER CANCELLATION SHOTJLDANYOFTHEASMOESCF68EDPOUCMSBECANCO- M EFORE TFIE EXFIRIC`[iOTi uATC TH'i,�ic,iiOTw'c:Y,LL comic tira�'....n��ne�n lu Town of Southold ACCORQANCE WITH THE POLICY PROVISIONS. 53096 Route 25 Po Box 1179 AU1HQR2WRB3ftWAT= Southold,NY 11958 JCB 01888201SACORD CORPORATION. All rights reserved. ACORD 25(20103) The ACORD name and logo are registered marks of ACORD Printed by JCB on INSy 31.2019 at 11:34AM Sep. 3. 2019 1 ;51 PM No. 0673 P. 17 I►I` e l c MwYarh3Wta Idautomw Fund 8 CORPORATE CENTER DR,3RD FLP,MELVILLE,NEW YORK 117473129 1 nyalf com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE Ol A PIAA A, 3312"26r SPECIALIZED INSURANCE& SERVICES INC ■ 204 ROUTE 112 PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JJO/�ES UNDERGROUND UTILITIES INC TOy�W{�',N OF SOUTHOLD 'i 0jLL D -Rll a J��JIJ�7J ROUTE 2-5- RIDGE RIDGE NY 11961 PO BOX 1179 SOUTHOLD NY 11958 POLICY NUMBER CERTIFICATENUMBER POLICY PERIOD DATE 12117 309-2 222711 0811012019 TO 08/10/2020 8/3/2019 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE 1S INSURED WITH THR NEW YORK STATE INSURANCE FUND rr��U,NDER ��POL��II�CY NO.�1{2157309-2,`/�! COVERING THE y ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR %NFORf ERS COWIPENSGATIO O UNDO=R THE 1\Giai YORK U RIKERM, Wivi flitSATKYN LAM uIITU O`vii g)w's TV nLL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WESSIPE AT HTTPSdM WW.NYSIF.COM(CERT/CERTVAL,ASP.THE NEW YORK SPATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. JOSEPH ROSSON(PRES)OF DOES UNDERGROUND U iILI fits FUG (ONE PERSON CORP) THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, WEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR INSURANCE FUND UNOERWRffWG VALIDATION NUMBER:240805638 U-26.3 Sea. 3. 2019 1 :51 PM No. 0673 P. 18 „'s f Compensetlon Workers' CERTIFICATE OF INSURANCE COVERAGE �� _ (30fttd DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1,To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier is.Wgai Name&Address of Insured(use street address only) ib.Business Telephone Number of Insured JOE'S UNDERGROUND UTILITIES INC 631-484-6512 8 GULL DiP ROAD RIDGE,NY 11961 tc.Federal Employer Identification Number of insured or Social Security Number Work Locattan of Insured(Only requ)red Irooverags k specilrcaiyllBtaff to cerfafn koflansIn NewYarl( tele,i,a.,Wrspolp Policy) 331212677 1 Name and Address or Pirdly Rsquesilng Proof of Coverage 3a.Name of insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPolnt Ute Insurance Company TOWN OF SOUTHOLD 53095 ROUTE 25 sb.Poky Number of Entity Elated in Box"is, PO BOX 1179 DBL260877 SOUTHOLD,NY 11958 3o.Policy effective period 09122!2018 to 09/21/2020 4, Policy provides the feiiowing benefits: ® A,Both disability and paid family leave benefits. B.Disability beno0ts only, C.Paid family leave benefits only. 5. Policy covers: ® A.All of the employer's employees eligible under the NYS Pisability and Paid Family Leave Benefits Law. ® rd.Only the following class orclasses or empioyees employees: Under penalty of perjury,I certify that i am an authorized reprossntadve or licensed agent ofthe naurance carrier referenced above and Utas the named Insured has NYS Disability endfor Paid Family Leave Benefits insurance coverage as described above. Dab signed 9/3/2019 BY Rut 151mature of rnswance earnersauthomed representative or NYE L¢e sed Insurance Agent of that Insurance carried I"elephoneniumbar 516-829-8,Od Name and-isle Richard While, ChierExecutiye Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form Is signed by the Insurance carrier's authorized representative or NYS Licensed insurance Agent of that carrier,this certificate Is COMPLETE.Mall It directly to the certificate holder. If Box 49,4C or 5B Is checked,thls certificate Is NOT COMPLETE for purposes of Section 220,Subd,B of the NYS Disability and Paid Family gave Benefits Law,It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 6200,Binghamtoh,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B of Part 1 Has been eheekedj State of New York Workers'Oompensatlon Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Data Signed By (502ture ofAuthorned NY5 Worliera'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carders licensed to write NYS dfsabigly and pald family leave bents Insurance policies and NYS licensed insurance asonis ofihose Insurance carders are authafzed to issue Poral 414-920.1.Insurance brokers ars N07autharbod to issue this room, D8420,111(1047) DB 120.1 (10-17)