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HomeMy WebLinkAbout8475 Cox Ln Permit No. TOWN OF SOUTHOLD yFFDI* HIGHWAY DEPARTMENTa`� Peconic Lane - Peconic,New York 11958 o r, (631)765-3140 '®1 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 Tyne Name of Applicant Phone Number Address of Applicant Name of Contractor Phone Number Address of Contractor d 9 17 3. Name of Property Owner Requesting Service(if applicable) Address of Owner J S 4. A/�GtJ GEG�'�/G ��/�!/lG� �p�I/7i1, 141,pl?D IA16 601C GAI✓oe 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. ol NOTE: All information requested by this gn re o licant Application/Permit Form is Required for a complete application! D to 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 3 Block Q 3 Lot 7. Starting Date: Z Z Completion Date: 8. Work Schedule: Phase Comifletion Date Excavation r ai D 'L o Work Schedule Facility Installation {5 ip 1-0 Must be provided Backfill&Completion O 2- o 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. 00 10. Estimated Cost of Proposed Work: $ 92� / O 10 O•o 11. Remarks: /I/r,7 J� D-39 1 of 3 12. Insurance Coverage:(Attach Copy) •(a) Insurance Com any: (b) Policy (c)State whether policy of certification on file with the Highway Department: (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$2,000,000 general aggre ate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (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.,qct Al. /Service Connections excavations @$50.00 $ ® % y U 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 $ 1/1 No. ©e 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 Exc ation permit to: in acc dance w' this application and subject to the"General Conditions"and"Special Conditions"of permit(if y)a ched er SUPERINTE N YS TOWN OF S TH O Vincent M.O�l0 Date Date Received by the TownClerk f ZA Date Permit Issued t`W Z0 Permit No. 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# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 1st 2nd 3rd 4t' (To Permit Clerk) REMARKS I 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 wuw.dignetnycli.com N �"� PROPO5E0 WATER METER or www.call8ll.com '�' ST/r>si �0 PROP05M WATER 5ERVIGE (for other states) ��p CONNECTION POINT S59055'31 T 63.14' �'� �• x,540'+5 D EA5TIN6 UTILITY POLE W/EXI5TIN6 U16 5B GURRB4f1.Y PROVIDED TO EX.OFFICE TRAI neowners are strongly 0 28(SERVIGE TO BE REWORKED TO PROVIDE F veil when planning any 5 . 53. AND 6OMMUNIGATION5 TO PROPOSED BUILT property. Homeowners 52.4 W 530 it 1-800-272-4480 or by EXI5TIN6 516NA6E TO REMAIN +530' REPUTED LOGATION OF ial call before you dig PROPOSM I" RPZ IN HOTBOX ON P.G. EXI5TIN6 WATER MAIN ti work completed on ��FOR INFO5EE. 'RPZ PLAN' S t is the contractor's "7 r • 52 - W iomeowner's—to contact, MAINTAIN ALL REGOIRID 5&ARAnOH + lines marked prior to DISTANGES WHILE INSTALLING PROP05ED gg" A 56.3 A., .e of charge. WATER SERVICE 543 EXI5TIN6 STORM DRAINAGE TC •3(� -J2 LEACHING POOL,TOG=EL 52.5' �'_ NO R1614T OF HAI bV x S'DP TO REMAIN 54 3 �C��� n�'�c EXI5T WITHIN 500 1 LMEASURE: WO/F NORTH FORK 53A � O� y Of PROPERTY GE A5 SHOWN. FENCE SHALL BE RE50URGE5 ING. - �0 X164M DEMOLITION/ (GOMMERLIAL BUILDING 553 2 %• G) NO SURFACE WATER5/WETLAN iA5E5 AND REMAIN IN WDRKING WITH PIBLIG WATT WITHIN 300' OF PROPERTY Lit L PROJECT COMPLETION g EXISTING STORM DRAINAGE IMM 5ERVIGE SHALL.BE \ q ��!�� LEAGHIN6 POOL,TOG=EL 523" ROM THE EXI5TIN6 S'(P x 5'DP TO REMAIN AND PARTIALLY 58 / 2 INE EXTENT INDIGATi=D ti .+� r �,� EXISTING POWER/GOMM.SERV. TO BE REHORKB �c� a, 5 'STUB IF' IN LOCATION NEARBY EX. ELECTRIGAL REQUIRED 5PLIGE/JmGTION BOX FOR INTERNED )N OF PROPOSED �� s� POINT. FOR CONTINUATION OF POWER/COMM. 2 SERVICE LIME 566 5EE PARTIAL 51TE PLAN On DWG) E PLAN (THI5 DWG) RY STORAGE 3 EXISTING E1 TRIGAL TO RI34AIN TO 13E REMOVED 1�ANa ,- ),I THRU No.12) WoIF JOHN 8 5U5AN DRO5KI5KI )N TO EXIST.SAN.SYS.: �o: SI COMM>�G1AL Bu1LD1Ns o10r- WELL 150+ DUTY 5EPT1G TANK 6 1 ��� BY REMOVAL +64.9' 414.4 _ �_ 58.1 & JR 5GDH5 REQT'INTS66 4` S FTC. 5>3ZNJ � X' ')LAN FOR NEW 5EPTIG GHIN6 POOL si���JC ® Tp EAC pAN g E COVER 67 2 _ �ST��N b RE14AIN" •• yq/,y G01 'LAN FOR NEW SLAB T 6 `�r � �t',� `�. .7, 9 \T� 46y�` EXISTING �IT ASS5 J RAILER 3 \ F ;�/ PG.5LAB TO RECEIVE \V 6 5" RETIRED.- 5T WEI l 1- � 1 PROPOSED BUILDING 650, i 6 4 (5EE PROP05ED PARTIAL EXISTING 'N, PLAN,THIS DW6) �� / TEST �O•�. :_ ABANDONED hlEl 'ERTY LINE :. - ®HOLE / EX15TIN6 ASP TO REMAIN ENT +6655.1' q �,� 4� TO 8E DATE(MWDD/Y M ACoR®O CERTIFICATE OF LIABILITY INSURANCE ovos/2ozo THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Jennifer McGroarty NAME: Maloney and Maloney Inc PHONE (631)728-0400FAX (631)728-0695 C No EXt: A1C No): 108 West Montauk Highway E-MAIL I @ y-malone ennlfer malone com ADDRESS: y P 0 Box 1024 INSURER(S)AFFORDING COVERAGE NAIC tl Hampton Bays NY 11946 INSURERA: Merchants Mutual Ins.Co. 23329 INSURED INSURER B Cell Electrical Lighting,Inc INSURERC: 255 Riverhead Road INSURER D: INSURER E Westhampton Beach NY 11978-1206 INSURERF: COVERAGES CERTIFICATE NUMBER: CL201910864 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 j INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR 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. INSR POLICY LTR TYPEOFINSURANCE NSD WVD POLICYNUMBER MMIDD F M/DD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DA CLAIMS-MADE �OCCUR PREMISES(E�arrencs $ 100,000 MED EXP(Any one Derson) S 5,000 A Y CMP9143267 10/05/2019 10/05/2020 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATEUMITAPPLIESPER: GENERALAGGREGATE S 2,000,000 X POLICY❑JEST LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident) ANYAUTO BODILY INJURY(Per Person) 5 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE S AUTOSONLY AUTOS ONLY Peracddent UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE AGGREGATE S DEC) RETENTIONS S WORKERS COMPENSATION PEROTH- AND EMPLOYER$°LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N f A E.L.EACH ACCIDENT S OFPICERIMEMBER EXCLUDED? (Mandatory In under If yes,describe under E.L.DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATIONS below E L-DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddlUonal Remarks Schedule,maybe attached It more space Is required) CERTIFICATE HOLDER IS INCLUDED ASAN ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF SOUTHOLD ACCORDANCE WITH THE POLICY PROVISIONS. HIGHWAY DEPT PECONIC LANE AUTHORIZED REPRESENTATIVE PECONIC NY 11958 ©1988-2016ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD - NYIF New York State insurance Fund! 199 CHURCH STREET.NEW YORK,N.Yr 14007.1100 nysif com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE e e h n a n 112460157 KEEVILY,SPEkO-WHITELAW INC. 600 MAMARONECK AVENUE HARRISON NY 14528, SCAN TO VALIDATE AND SUBSCRIBE POLICI'HOLDER, CERTIFICATE HOLDER CELI ELECTRICAL LIGHTING INC TOWN OF SOUTHOLD 255 RIVERHE=AD RI? HIGHWAY DEPARTMENT WESTHAMPT©N BEACH NY 11978 OECONIC LANE PECONIC NY 11958 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G10613664 699136 1110112019 TO 11101!2020 11912424--1, THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO,- 1661366.9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT -T6 ALL OPERATIONS-IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELI.ATONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:11WWW..NYSIF.COMICERTICERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENTOF FAILURE TO GIVE SUCH NOTIFICATIONS, THE POL'ICY'INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNbER WHICH NYSIF 'AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER-AMOUNTS WE PAID IN WORKERS'COMPENSATION ANDIOR MEDICAL BENEFITS TO,OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED' INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS -CERTIFICATE DOES NOT ,AMEND, EXTEND OR, ALTER THE:COVERAGE AFFORDED BY THE POLICY, NEW YORK,$TATE INSURANCE FUND DIRCCTOR,INSUI MCF-FtiNDtlNGERWRITING VALIDATION NUMBER:579689887