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HomeMy WebLinkAboutHound Ln/Greenwood Rd Permit No.AN3 TOWN OF SOUTHOLD F014&r HIGHWAY DEPARTMENTi� Peconic Lane Peconic,New York 11958 106- (631)765-3140 01 � 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 Twe e t44r1:'i K�� ZL,,�'K_X/J t 60 1�3� 14-20 1 {-LZ6&)41V tJ(T F/. 1,3y Name of Applicant Phone Number Address of Applicant 0(1 317 0 2. � 2lc�C: �� ���-Z0771qI 6LO + 5 + lam• i.E ? a^y Name of Contractor Phone Number Address of Contractor Namee of Property Owner Requesting Service(if applicable) Address of Owner ©E,3- p 4. _t NkW 7+LL.. NI&W (2 k /C--�. "(-j P WAL5t( PAeZ ihND LAwe l(1Z6FA W_0DD Work Description and Location(Street Number Hamlet Cross Street) aa � IZF�• (a) Is construction located within 75 feet of tidal wetlands? *Yes No Ivy *If yes,other Town permits may be required. �d NOTE: All information requested by this Signature of Applicant Application/Permit Form is Igo Required for a complete application! 6 �Zo 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 /Z Block / , Lot 4,4 7. Starting Date: IS -T(A `20,60 Completion Date: FLAY 1 51 2&2D 8. Work Schedule: Phase Completion Date Excavation / 14 2,3eo 2CY/� Work Schedule Facility Installation SOT* SoZD Must be provided Backfill&Completion A 94L- & 'rP for consideration as a Pavement Replacement Ae iV L, 20 Complete Application. 9. Under which authority is application being made: F MC-'Ge-�, L)I 1 LCT( CO. ,6Va4G7 F�- -See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ �� 11. Remarks: D-39 1 of 3 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: N C-W 'YbQ�i— 6 T ,M ioJ 15u iL/{ i J6& (b) Policy#: --,,z + :315 '41 g_v (c)State whether policy of certification on file with the Highway Department:_ t4® (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$2,000,000 general aggregate. 13. Security: 1 --- (a)Surety Bond_ or Certified Check provided in the total Amount of$ (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 $ 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 de th 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$ �i,0 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: in accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(A any)attached ' et SUPERINTE ENT F S TOWN OF UTH RK II in 11 ndo Date Received by the Town Clerk �'!12� at Date Permit Issued "L(24( 2,0 Permit No. l 3R 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 NY S I F 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State Insurance Fund nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112232368 LOVELL SAFETY MGMT CO.,LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 [mile SCAN TO VALIDATE AND SUBSCRIBE `y•` �. POLICYHOLDER CERTIFICATE HOLDER ADJO CONTRACTING CORP TOWN OF SOUTHOLD NN 207 KNICKERBOCKER AVE HIGHWAY DEPARTMENT BOHEMIA NY 11716 P.O.BOX 178 PECONIC NY 11958 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE Z 1061 937-7 863723 04/01/2020 TO 04/01/2021 03/04/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1061 937-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION_ LAW WITH RESPECT TO 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 CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:/IWWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH — NOTIFICATIONS. THIS CERTIFICATE DOES NOT APPLY TO THOSE JOB SITES WHICH ARE COVERED BY OTHER INSURANCE AND ARE SPECIFICALLY EXCLUDED BY ENDORSEMENT. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER 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 AND/OR 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 STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 616362462 1111111 II11Illm ICE ilia000u000010�0000796274�611M111A111 Fonn WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-10619377] U-26 3 30 [00000000000079627461][0001-000010619377][##Z][15333-30][CerLNoP-CERT 1][01-00001] • v IC - .a►co CERTIFICATE OF LIABILITY INSURANCE " = DATE(MM/DDIYYYY) 11 12/16/2019 THIS CERTIFICATE IS4SSUED AS A MATTER`OF INFORMATION ONLY AND CONFERS NO•RIGHTS UPORJ; 1:-CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATIVELY AMEND, EXTEND OR ALTER THE COVE '�GAFFORDED BY•~THE POLICIES BELOW. THIS'CERTIFICgTE-OF II�SURANC€ DOES NOT CONSTITUTE A CONTRACT BETWEEN THE'ISS,UING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER;AND THE'CERTIFICATE HOLDER. = IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisionsfor be endorsed. . If SUBROGATION IS WAIVED,subject to the,terms and conditions of the policy,certain policies may r'aquire,aendorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT- NAME: O TACT NAME: New York Risk Solutions,'inc. PHONE631-673-1800 ac Ne:631-673-1801 150 Broadhollow Rd. _ E-MAIL ' Suite 355 ADDRESS: certificates 6n risksolutions.com " Melville NY 11747 s INSURERS AFFORDING COVERAGE NAIC p INSURER A:Mt.Hawley Insurance Company ' s-37974 INSURED BDREM-1 INSURER B:Crum&Forster Indemnity Co. `31348 BD Remodeling and Restoration NY LLC 1420 The Gloaming INSURER C: Fishers Island NY 06390 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:496689992 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 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. ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MGLO187811 10/3/2019 10/3/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE �OCCUR PREMISES Ea occurrence $50,000 X CONTRACTUAL LIAR MED EXP,(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $2,000,000 POLICY E PRO- JECT F—]LOC PRODUCTS-COMP/OP AGG $1,000,000 OTHER $ B AUTOMOBILE LIABILITY 133-746886-8 12/12/2019 12/12/2020 COMBINED SINGLE LIMIT $1;000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident AUTOS ONLY AUTOS ( ) $ HIRED NON-OWNED PROPERTY DAMAGE ' AUTOS ONLY AUTOS ONLY Per accident $ X HIREDAUTO X NON-OWNED $ A UMBRELLA LIAB X OCCUR MXL0430702 10/3/2019 10/3/2020 EACH OCCURRENCE $5,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ WORKERSCOMPENSATION PER OTH- AND EMPLS OYERS'LIABILITY YIN TATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE , OFFICERIMEMBEREXCLUDED9 ❑ N/A E L EACH ACCIDENT $ (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) THE FOLLOWING ENTITIES ARE INCLUDED AS ADDITIONAL INSUREDS ON A PRIMARY AND NON-CONTRIBUTORY BASIS AND WAIVER OF SUBROGATION APPLIES IF SUCH STATUS IS REQUIRED IN A WRITTEN AND EXECUTED CONTRACT AS PER ATTACHED ENDORSEMENT CGL-2033 AND CGL-2037. WITH RESPECTS TO:WALSH PARK FREIGHT BUILDING HOUSING,544 HOUND LANE,FISHERS ISLAND,NY 06390.:TOWN OF SOUTHOLD. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN HA TOWN SOUTHOLD ACCORDANCE WITH THE POLICY PROVISIONS. 53095 ROUTE 25 AU ORIZEDREPRESENTATIVE P.O. BOX 1179 SOUTHOLD NY 11971 �/y� 0©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD REMODELING & RESTORATION - March 11 th 2020 Chris Finan President FI Utility Co &General Manager FIDCO 161 Oriental Ave,#604 Fishers Island,NY 06390 Office 631-788-7251 Cell 860-803-1603 Chris This letter is to notify the Fishers Island Water Company that BD Remodeling and Restoration intends to install a new 12"water main extending the existing 6"water main to supply water to new Walsh Park Freight Building Apartments. All work is to be completed per plans and spec By JR Holzmacher P.E. for Fishers Island Utility Company proposed 12"water main,installation,Fishers Island Ferry district,261 Trumbull Drive, Fishers island NY dated Dec 17th 2019,including sheets C-1 'thru C-4. Mark D Richards BD Remodeling and Restoration Senior Project Manager 860-912-9537 THE GLOAMING,BOX 447,FISHERS ISLAND,NY 06390 TEL-(631')788-7919- FAX (631)788=7192