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Home My WebLink About5250 Vanston Rd Permit No. TOWN OF SOUTHOLD .�g11FF0I,�c HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 10 (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 Applicant 2. Cc AacAviACCS Name of Contractor Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4. In ( lC `� fY-nc) Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. NOTE: Ali information requested by this Sign plicant Application/Permit Form is yy Required for a complete application! I I 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 Kj Lot 7. Starting Date: I L4 Ig Completion Date: I /i f 8. Work Schedule: Phase Completion Date Excavation -11/1411q Work Schedule Facility Installation Ll I t. 14 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 too 11. Remarks: l ceo Yc.J� Tc-mi O-e(hY iG —(6 C"e) rn ss l t-e-- 4— AI�MCNnq- D-39 ' 1 of 3 1 Y-6es ecp ck ,f;'y�], 1rl,i r i' -'�� ''I } rr,4'� ',• �J�/i./ t;''I ®V ,71 `,M 00 , I , a•. „_(' „ .l. r .. I' t' . "t;it,.t. '�• Ii.r _z t -�- �• f , y , '4 y . , - 4 - _ _ .•fir ,. •. -' , 1 , 1. - ' 12. Insurance Coverage:(Attach Copy) /+ (a) Insurance Company: [ �U�- S Co- (a) (b) Policy#: i (c)State whether policy of certification on file with the Highway Department: Or (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 $ �Jy V. L 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. 0 Utility Repair Excavations @$1,000.00/Each $ Additional Repairs of Same Service @$500.00/Each $ o. TOTAL$ � 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 Excavation permit to: i ccordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any attached hereto. SUPERINTENDE S TOWN OF SOU O , E V' cent AT ran o /1 /y Date Date Received by the Town Clerk I �R Date Permit Issued I I I GLI 1� Permit No. (0� 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: Permit# l 36y Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1St 2nd 3rd 0 (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 .� Verizon • . ; - c Al , 9913 _ a,-4o , Iu YyijVi.CA. ` `t "U ICS r�'6 d� s tC i n. 4., ,.r ,x+ , >...>r�?.• cif ten", '.n... � r ... .. ) .I�� xy�_"G� nY,i t -..-..,.c rt -- i ,n i ..1, ,... " _ i ACO CERTIFICATE OF LIABILITY INSURANCE DATS(MUMONMI L.,..� 11/06/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CFRTWI"TF nnFS 1M1T ARCHMATRtMV fW nf1:P_A-rn1=V Ae =Wn IMV-MUft nn AT-POM *ur wwa.rn- .. .. -BELOW. THIS CERTIFICATE OF INSURANCE DOES-NOT CONSTITUTE A CONTRACT BETWEEN THE 188UING IN8URER{S}, AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED,the policy(lest)must be endorsed. H SUBROOATION IS WAIVED,subject to tho tonna and conditions of the policy,certain policy may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such ondorseme s. PRODUCER EILEEN CUSHMAN VINCENT C DALEY P:! —4131.722.d4nn RAX-.._..ttzt--7*9-Arun PO 8LuX 2336 -Anogate` .EILEEN CUS AN-NATIONAt.COM 1116 MAIN ROAD INSUR S AFFORDING COVERAGE NAiCI AQUEBOGUE,NY 11931 INSURERA:FARM FAMILY CASUALTY INS.CO INSURED INSURER a PATRIOT CONTRACTING CORP — — PO BOX 351 INSURER C: 1AtCCTR4IIttA0TnAt AIV 4Irn" INBURERD: - ------- -- ` 'rifalinER e: I INSURER P: COVERAGES CERTIFICATE NUMBER: RE=VISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSOWOR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOITIONS'OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ IXX coMMERCU11eENERAI.te[HSRT X 3102X1171 17212019 K212020 EACHOCCURRENCE f 1.000,000 CLAWS-MADE OCCURrrorwal S 100.000 _--- MED EXP(Any oneperson) i 5,000 PERSONAL 8 AOV INJURY f 1.000.000 GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 XX,POttCY ;w"rr Ir�Lt>C narttttrrrc_rnlaarno srsn e s nnn_nnn IOTHERED SINGLE ti AUTOMOBILE LIABILITY dsfl U S - ANY AUTO BODILY INJURY(Per person) S ALL OOSWNED SACOEOSUI.ED. BODILY INJURY(Per accident) S NON-OWNED PROPERTY OAMKdE i - I HIRED AUTOSAUTOS . S A JLI(R J t✓V I VJ I J J V I!I GGV 1'.7'V!7{"Z%jewEACH OCCUARENCE I b D,000 V V V -. _�EXCE88Ltm CLAIMS-MADE AGGREGATE DED RETENTIONII f WORKERS COMPENSATION S TUTE ER ,ANDEMPLOYERS'LIABILITY IN ANY PROPRIETORRARTNERIEUCUTNE E.L.EACH ACCIDENT f (Mandatory In NNI EXCLUDED?r N/A E.L.DISEASE•EA EMPLOYEE f 1f Yes gescnb®ur+der--_------ - DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101.Addtrional Ranarka Bohoduts,maybe allached U more aprtoe to regal" CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 MAIN RD ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORIZE EPRESENTATIVfi /j tM4RRR-2a4AAf!npnt%AglPe%PAtleIN All rrrnhfc manornlw.f ACORD 2512014101) The ACORD name and ioao are realstered marts of ACORD I RK I Workers' CERTIFICATE OF ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board Ia.Legal Name&Address oflnsured(use street address only) 1b.Business Telephone Number of Insured PATRIOT CONTRACTING CORP POB 351 WESTHAMPTON,NY 11977 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured 10rty tequlmd 11 coverage is speciiicaly fimfted to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York Stale,l e.,a Wrap•Up Pof$ Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Canter (Entity Being Listed as the Certificate Holder) FARM FAMILY CASUALTY INS CO Tnuwe nr nne eru.�.n 53095 MAIN RD 3b.Policy Number of Entity Listed In Box"le SOUTHOLD,NY 11971 3103W7433 3c.Policy effective period 08112/2019 to 08/12/2020 W ❑ Included.(only check box If all partnersh dicers included) ❑X all excluded or certain partneWo(ficem excluded. This certifies that the Insurance carrier indicated above in box'W insures the business referenced above in box'I a'for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Rom 3A on the INFORMATION PAGE of the workers'compensation Insurance policy). The Insurance Carrier or its licensed agent will send •••••'••..••••' •�•• •-o'knt:.4!__w V!gvt�-rh ve-4 V V%r'7 ee...Q`_.d4+114�3:';tWIMs4 k1l"Wa 6. i Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the and of the policy effective period?, []YES ❑NO This certificate Is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or after the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the ra;arancou N:,p y. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy Indicated on this form,If the business continues to be named on a permit,license or contract Issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers Compensation Coverage or other aulitedzed proof that the,business-Is complying with the mannatory coverag'va4aagflirrornerrrt�ar trier mew orK awe worgam Law. Under penalty of perjury,l certify that 1 am an authorized representative or licensed agent of the Insurance carder referenced above and that the named insured has the coverage as depicted on this farm. App6ve�by; VINCENT C DALEY Approved by: (Signature) (Dote) Title:AGENT Telephone Number of authorized representative or licensed agent of insurance carrier. 631-722-4100 Please Note:Only Insurance carriers and their licensed agents are authorized to Issue Form C-105.2.Insurance brokers are NOT authorized to issue It. C-105.2(9.15) www.wcb.ny.gov ,�. , Ticket: 193090900 ny@occinc.corn To- info info@patriotcontractingcorp.com n,?t e- Tuesday, November 5, 0928 New York 811 Ticket No: 193090900 ROUTINE Original Call Date: 11/05/19 Time: 9:20 AM WEB Start Date: 11/08/19 Time: 7:00 AM Lead Time: 20 Caller Information Company: PATRIOT CONTRACTING CORP. Type: CONTRACTOR Contact Name: CHANDRA MORCERF Contact Phone: (631)283-2240 Field Contact: JOSHUA CARRICK Alt. Phone: 1631)283-2240 Best Time: Fax Phone: f631)283-2004 Address: P.0 BOX 548 P.0 BOX 548; SOUTHAMPTON, NY 11969 Email Address: info@patriotcontractingcorp.com Dig Site Information Type of Work: INSTALL ELECTRIC CONDUIT Type of Equipment: TRENCHER Work Being Done For: RONY ELECTRIC In Street: X On Sidewalk: X Private Property: X Other: Front: X Rear: X Side: X Dig Site Location State: NY County: SUFFOLK Place: ORIENT Dig Street: OLD MAIN RD Address: 31545 Nearest Intersecting Street: GRANDVIEW DR Second Intersecting Street: MAIN RD Location of Work: MARK BOTH SIDES OF THE STREET AND SIDEWALK FOR THE WIDTH OF THE LOT TO INCLUDE THE ENTIRE PROPERTY FOR INSTALLATION OF NEW ELECTRICAL SERVICE FROM UTILITY POLE LOCATED ACROSS THE ROAD FROM THE PROPERTY Remarks: Map Coord NW Lat: 41.152731 Lon: -72.274635 SE Lat: 41.151314 Lon: -72.272996 Operators Notified: CBLRH01 - CABLEVISION OF RIVERHEAD LIL - NATIONAL GRID LIPA02 - LONG ISLAND POWER AUTHORITY SCWA01 - SUFFOLK COUNTY WATER AUTHORITY VZL - VERIZON COMMUNICATIONS Link To Map for C_EMAIL 1 / 2 �; ESPONS MARIBI WITI E -V C T 'i'IMAIP'OURK-TAIN,'I ',,,INIOTE!,,,�YOU'MUST'.CO NTA7T-,ANYK,-bTHER-WTI v ATOR tfS, 2 / 2