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Home My WebLink About31545 Old Main Rd f i r Permit No. WO. TOWN OF SOUTHOLD 4�SUFFag�.�� HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 0 (631)765-3140 y� 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 Tvpe 1. � Cocoa ,Mky&-Al tel- S , Name of Applicant Phone Number Address of Applicant 2.?&41R� ,4 02dQD J C' Name of Contractor e Nu er Address of Contractor 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4. �1 qkc--l-r-icM 1` Nn` OA C �-� �- ork 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: All information requested by this Signator scant Application/Permit Form is 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 3A 7. Starting Date: I I—1 �� "1 Completion Date: 11 1 LA 119 8. Work Schedule: Phase {ff ''ll Co letion Date t Excavation L � Work Schedule Facility Installation I IQ i Must be provided Backfill&Completion 117104 for consideration as a Pavement Replacement Complete Application. a 9. Under which authority is application being made: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. '50 Qf !�e�re 10. Estimated Cost of Proposed Work: $ 11. Remarks: 46 do i ` D-39 1 of 3 1000 (ALA , 12. Insurance Coverage:(Attach Copy)-�� (a) Insurance Com anyry ' (b) Policy#: �0 X I m (c)State whether policy of certification on file with the Highway Department: ac"a ked (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. Al. —J—/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. 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 wit this application and subject to the"General Conditions"and"Special Conditions"of permit(if an attached heret SUPERINTENDE S TOWN OF SOU W RK V' ent M.brl!v� / l � Date Received by the Town Clerk �( I`Q t Date Date Permit Issued Permit No. (3 (0 NOTE: Permit expires one(1)year from date of issuance. No work to start without 24 hour notice to Superintendent of Highways. Pen-nit must be available at all times for inspection,on site,during construction. �i D-39 2 of 3 a Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S_RECORDS Inspection Date Findings (use code) Applicant Notified 1St 2nd 3rd 0t (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 4 =, LA- oz i�y' �cctca (2) 58 j � ^` 'rid'. -., �• - ';d, M' - wn.' �r'.�y.Y ,K ACO® CERTIFICATE OF LIABILITY INSURANCE oATB(MwDOmm1 11/06/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CFRTIFIL`Aw nnMC Mnr &vviDuATNCI v no NCP_ATnMI V Aueaen r.VT=Uft w® A\-Fr--n VU1- 68A\fPRAI\P Ar-w�w R .- BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(Me)must be endorsed. H SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate doss not confer rights to the certificate holder In Ileu of such endorsome s. PRODUCER EILEEN CUSHMAN VINCENT C DALEY I MRS__..1331-722-A1nn I tAE PO BOX 233n 6"°'�' .EILE NN.CUSHMAN ERICAN-NATIONAL.COM 1116 MAIN ROAD INSURER(SI AFFORDING COVERAGE _ NAICS AQUEBOGUE,NY 11931 INSURER A:FARM FAMILY CASUALTY INS.CO INSURED aeURBR e PATRIOT CONTRACTING CORP —� PO BOX 351 INBURIM 0. IAICCTLJAaACrrfNkl AIV 14077 INSURER 0: ` I1i917WFJ1 H: { INSURER P: COVERAGES CERTIFICATE NUMBER: REVISION 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 ISSI)WOR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS'OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I Paudy I Pfd aP COMMERCIAL GENERAL UAIKIM X 3102X1171 07/12120190711212020 EACH OCCURRENCE S 1,000,000 CLAIMS-MADE ❑OCCUR S 100,000 MED EXP areperson) i FJ 000 PERSONAL a AOV INJURY $ 11000,000 GEN L AGGREGATE LIMIT APPLIES PER` GENERAL AGGREGATE 5 2.000,000 xX, POLICY 'RAR- LOC oonry ir-Te_rnuone enn e 2 nnn nnn I I OTHER S 'AUTOMOSILELIAa1LITY $ —- ANY AUTO BODILY INJURY(Par person) S—- -- r1 ALL OWNED SCHEDULED. BODILY INJURY(Per accident) S AUTOS AUTNO"WN 790—P pAMAG S E HIREOAUTOS AUTOS _. 5 uquwvi�r,S^ IA1 OCCUR �V%!IZUUIU Ui 1LJLVLUEACH(JCCURRENCE S \7,VVV.UVU EXCESS UAB CLAIMS-MADE AGGREGATE DED 1 RETENTIONS t; i WORKERSCOMPEN8ATlON R AND EMPLOYERS'IJABILnY r N S UTE R ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S OFFICryInREEXCUIDED7 r NIA to -- E L.DISEASE-EA EMPLOYEE S Ryes dasunCe urlder___ - 1 DESCRIPTION OF OPERATIONS I LOCATIONS!VSNICLE8(ACORO 101,AdMonat Remarks SohadWa,maybe anashad Rmcfe apses Is rogWmd) CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE MLL BE DELIVERED IN 53095 MAIN RD ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORMWEPRMNTATIVra (O 1RRR-4n1d®GARB r'ARPArdA AN ®II ednhtw eeeawevwel ACORD 2S 12014101) The ACORD name and loco are realstered marks of ACORD yEW Workers' CERTIFICATE OF aTE I Board Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE B 1a.Legal Name&Address of Insured(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(Only requ fed if coverage is speaftally AmNed to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in Now York State,le.,a Wrap-Up Polley) Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity,Being listed as the Certificate Holder) FARM FAMILY CASUALTY INS CO Tnuw!nr n.lrun!n 53095 MAIN RD 3b.Polley Number of Entity Listed In Box'Ie SOUTHOLD.NY 11971 3103W7433 30.Policy effective period 08112/2019 to 08112=0 `ti.• • • o.0 w.o w r.�oy}u4o y.,e.d..n v..a r. Included.(Only duedc box If all pannerstafrosrs included! Qx all excluded or certain partneWoftleem excluded. This certifies that the Insurance carrier indicated above in box'r insures the business referenced above in box'1a'for workers' compensation under the Now 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 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 cerfificate 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 orsitarthe coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the rGrrOmncaaa`Joucy. 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 Coveragie or other authorized proof that the business le complying with the 677arwatory%vvorayB roquirem"Gr,w of u,e Nevd Tom amw uvornurei i.&W. Under penalty of perjury,I certify that I am an authortud representative or licensed agent of the Insurance carrier referenced above and that the named Insured has the coverage as depleted on this form. Approve4 by, VINCENT C DALEY Approvedby: - .....�....._.___._._....._w...... .__..._...._... _ .._..///�..�: (Signature) (Date) 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 No authorized to issue It. C406.2(9-15) www.wcb.ny.gov z. ,, Ticket: 193090765 r -na., ny@occinc.corn Ib. info info@Darriotcontractingcor[o.com Date- Tuesday, November 5, 09:13 New York 81-1 Ticket No: 193090765 ROUTINE Original Call Date: 11/05119 Time: 9:01 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: (631)283-2240 Best Time: Fax Phone: (631)283-2004 Address: RO 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: CUTCHOGUE Dig Street: VANSTON RD Address: 5250 Nearest Intersecting Street: W BAY RD Second Intersecting Street: DEAD END Location of Work: MARK BOTH SIDES OF THE STREET AND SIDEWALK FOR THE WIDTH OF THE LOT TO INCLUDE THE ENTIRE PROPERTY AS WE ARE INSTALLING NEW ELECTRICAL SERVICE FROM THE UTILITY POLE LOCATED ACROSS THE STREET FROM THE PROPERTY Remarks: Map Coord NW Lat: 41.000569 Lon: -72.453461 SE Lat: 40.996974 Lon: -72.448870 - --Operators Nott#ied: 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 E''(C—AVAT- O"—ESPONS f 7-7 �,IMP'O,k�TAN-T,,'r'NOTE�'�.YO(J,-M-US,T,.,CONTAC-,T--,-,At.4Y-"O,THER,-�,,UTILITI'�F--'Sr-�DIREC-,TLY,,��-','e-- tn EX ��A�r '-"C- 2 / 2