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HomeMy WebLinkAboutAckerly Pond Rd Town of Southold • P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 10/26/20 Receipt#: 275974 Quantity Transactions Reference Subtotal 1 Excavation Permits 1428 $55000 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#10510 $550.00 Center, Island Services Inc Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Center, Island Services Inc 67 Sycamore Street Patchogue, NY 11772 Clerk ID: LYNDAR Internal ID. 1428 Permit No. I �! TOWN OF SOUTHOLD �g�FFOtor HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 0 ,� (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 Tyne a 1.j Lkn6naxsi R-dcecy (a 1 L175--5(000 C27 &,r-r7ev-e 5LA hc;a : ID key%Sll'l lic� Name of App — Phone Number Address of A plicant 2.1 AL(- Isktm kiry K.LS LAN' 415.54cx� 1 & OMA(f S f Name of Contractor Phone Number Address of Contractor V I 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4.E eC. -761cil 6 i Work Description and Location(Street N ober,Hamlet,Cross Street) y l (a) Is construction located within 75 feet of tidal wetlands? *Yes No /\ *If yes,other Town permits may be required. u NOTE: All information requested by this 6f Signature of Applicant Application/Permit Form is j Required for a complete application! ��)/2 -1 o Date i 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 pen-nits 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 1-1 1 E Q, 7.; Starting Date: A5 A P Completion Date: i w 8.! Work Schedule: Phase Completion Date Excavation Work Schedule l Facility Installation Must be provided Backfill&Completion for consideration as a i Pavement Replacement Complete Application. d 9.' Under which authority is application being made: ' See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. I 101 Estimated Cost of Proposed Work: $ i 1. Remarks: D13 9 1 of 3 � o i 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: lnSt.zance ('Or-1040V (b) Policy#: L 2l0 t00!A?jLpf5 { (c)State whether policy of certification on file with the Highway Department: 5= Q AllHe,A (d)Coverage required extended to the Town: Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed: I $1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: (a)Surety Bond On or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. f 14. Fees for Applications and permits: I Basic Application Fee for Each Project Location - $500.00 f A Project Location would include each Bell Hole and/or every road opening or excavation within any f 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 $ d36- 0 U No. I 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 $ R 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 $ j No. ! TOTAL$ F. Official Notice to public utilities-proof must be provided and I Shall be attached to this application prior to issuance of permit. i Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excav 'on permit to: i accor nce wit Ithis application and subject to the"General Conditions"and"Special Conditions"of permit(if )atta ed here . i SUPERINTEND T H H Y TOWN OF SOU H L Y f Vi cent M.Qr n I I v Z ZGZU Date Received by the Town Clerk 10 -Wo Date Lr Date Permit Issued �V - 2-0 Permit No. I j 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. I f D,39 2 of 3 r 1 Copy Distribution: �[ Permit# p ' Highway Department Engineer(with page 3) Applicant Town Clerk(Original) I E r t € INSPECTOR'S RECORDS i Inspection Date Findings(use code) Applicant Notified i 2nd 3 rd i I Atli (To Permit Clerk) REMARKS i j i i i CODE IB Improper Barricades Ili Improper Lights ST Sunken Trench or Excavation U,t'M Unable to Measure(due to backfilling) BUC Building Under Construction WIP Work In Progress DP Improper Backfill(too high,not sufficient) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair i `t 1 k D;39 3 of 3 f 4 f J s CERTIFICATE OF LIABILITY INSURANCE DATE{MM;DDNYYYJ 10+2012020 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 CONST{TUTEA CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. wrtificate holder is an 7015ITIONAL IRSURED,the policy(los)must be endorsed. ,sutoctto i the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confor rights to the certificate holder In lieu of such endorsement(s). PRODUCER yppaE; 70II37SChaako GroupicoverageInc ac"io E 516-3968275 Box'483 516576-0909 PD Bo ADDRESS: billaSroup wnrago net 516576-0007 DIsuRERlsi AFFORDINGCOVeRAGE NAIL d Vlo3t6111p NY 11795 INSURERA: Aflantla Casualty lasumrrm Company i 21792 _,._._____ sasuREo INSURERS: NGM Ins umnoo Company ? 14786 CDntorIsland Sorvlcas,Inc. wsuRERc: RkRTFORDACCID&INDCO 22357 67 Sycamore St INSURERD:_ t INSURERE: j PatChOguu NY 11772 1 iNSURERF: ? COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: T HIST IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR5 AMED ABOVE FOR THE POLICY PERIOD I INDIUATED. NOTWITHSTANDING ANY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTWITH 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. tNSR"-.1 w __ ...,.`_ . „M,,_' _.,.. _.._..ASDL'SUpR' _..e..w _ w wPOL1CY GRl` -POLiCY,P LTR t TYPEOI'INSURANCE pl p- POLICYNUMDER MMtDplYYY I MM)OD)YY i LImRs ! COMMERCIAL GENERAL.LIABILITY 1 1 rACHOCCURREVCE ;5 5.000.030 i.a._.._; 4,c AsuS.w4£ it,`o cuR i nEn±�cs�t I 50.000 i tXC iETIOC 4.. s 1 VM D(P IAayons pan at> :s 5.000 w A !; 1261004365 # 1010312020 = 10103/2021 PrRsaxAL&ADV INJURY i S 5.000.000 ,\3GRLGITEwarrAPPIESPER. ; r jGEti£RALRGGREv^ATE s 5.000.030 O_ICY' ECT `_ :DD t E € a PRODUCTS•CO.VMP AGG<s 5.000.030 ` } s } i'OTIIER 4TOMOBILELIAMLfTY t Lov. L•r:ra.ds-ns `IV IT 1.000030 �iAN'YAUTo A, 4 : ODDL'YLAJPY{Ptspe.�;ty ::5......... I s A°S STIED nEuJ:ED B , AUTO3 :AUTOS BIL14384Y ;1010312020 10+0312021 B ODDLY INJURY IP&acddete:s �D o\u�£a + i"�rtOPESNff,Pt�,tff£__ ii7l fiIREDAUTD:t }m AUTD9 �� l $ .1 l LL S � d i 9 t B € w A, UMBRELI.ALIAB a z OzQN1 - .EACI1OCCURRE\CE S i I E%CCSS LIAR I C_Ai\tS-MAr£ A3GREGATC S DED = i RETCENTIONS .g IWORIERS COMPENSATION e AND EMPLOYERS°L(AaILITV YIN R (STATrbTE w ER tAr;` CERA7AIDCR;MLUIal'UiE4JTtVC ) i I ELrJr-HMxID£..W 'S 1000000 C ;DTc crRa\sE�sa£n occcuD? N)Al 124Ve'.1U10ifYfal ;0 31 2 112 0 20 i 0312112021 ; — - --•I 41Mandatory inNHJ i £ ;E.L,D1SF,\SC-EAEMPLOYEa s 1.000.000..+ Ify6,deweba trtd r F rDMCRIPTIONOFOPCRATIO\St lex i E.L.GISMSE-PO_ICYUMIT, 1,000,000 � I t t i 1 4 DESCRUiMON OF OPERATIONS)LOCATIONS!VEIIICLCS p1CORD Ia1,Additbnal Raimrks Schadulo,nmy be alt=hod if more spaco fs mquhad) Certdir„ate is evidence of insuranoo for tho named insureds ubjv:t to terms.Conditions and exclusions. I CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Tovin of Southold ACCORDANCE WITH THE POLICY PROVISIONS. I 275 Peconic Lane AUTHORLLED REPRESENTATNE PDCDRtr NY 11958 � fr1�t'l.�ir✓�i ;�c�c�.rur�E� Q1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are rogistorod marks of ACORD i i , i ' C I g �—}fi j i t k tymc�ee ; _ 67 S $treat -; 3 -Patctio t )-4�r� oAm�+p�q. ci�ss ict: $fid �OPlt f6317174-85 98._ �# -�= - "�"T"---�-�-•-- �OHj .J 72 t ���—� .t-._ y-_._�._. _'_._ __ 4._ ._.d,_ .._ ___�—-• -`--- � ....�_ ..,.�.. _�.,:.�._ �`Jt7w ,f _ .,2 __.�•_ r_-..' ..�___��__3. _ _I"-•^�3�ri��.�4��`..�1_ 3d { P ii[I{ It tk S fir, � ..�$. ._— 3 # .i_._.._,.F-___" '���.�... S i •,�._.-_._».,..,...._ ___ .^ �»_ 3 q_.___?� # i -I--—•i � —� i t{ �"t ���' � ! ,}`__-____ f{jj{'' -.3..__..._______�_-__, n..._.. ..}E_ # t _.� .�..,_. � { I � �, ${p .»�. ` ; t � �.,�...._._, �• i � (f 5 .r � f - � j 3 E # t,`•,,,,- i i i } i i I � ±� �k� , w 7—i __.. »��.___..�_ "`C _...�.j -" _ .'_�•_ _•— •q___ �_ S_..._� - (;_.. _-,�.._ � _.. .—�iE. s _._._.p' -'.____.._._...._. _. ......_,....,�._._._.Z_w...f..�. 3 iv#�,,,, _.._=r•—_�I{--___ __I7_._- 7 ,,.. � .. { ..—. �_ —#__ _L�..._._ _ —�-t_ __ ,._ i — ._... _ . � 2- ' 44 a l ce THIRD PARTY CLAIM/Form Number. Referral Form DAMAGE NO COsNSTRUCTION ETB)RemedyTteket: DSTX127243316 REFER TO:FFacil'ii lDepL: v r ea Supervisar,1®.Greene, Tech#/Cell#: MHenkel/51662341126 REAsoN FOR WORK t: 0OfdSTRU6TiON REAsoN2; Pole: PS: Amp: Tap- DESIGN INFO ap•DESIGNINFO1ONLY DESIGN Maio.Type I TYPE 1 2FcalCorsn} Enstinq)Now SubscriW Repair LocaI1 n: 1405 Ackerly!Pond Lane r CORP 7&39 Account:` "356916,'_01. Date: September 5,2020 Name: Ward Phone. (631)7654518 Grk!/Msp. Address: 1 1405 Ackerly Pond Lane X-Street. Main Rd Town: Southold Hagstrom: ,..._;..,-:-.mvude Tt7 -;. .cut it oaD a rep acement is554 )7• '" ,:.: . Co Headend Node I CH2 CH70 CH119 603 MHz 693 MHz 747 MHz Tap Pre-Fault , 783x, Southold y x9b112 i Spliced Point:i Ground Block:t Tap Post-Fault l A.d.l wok(IlaQo:o uumbar(t)& nearo:t house mgna.rfa)1.1' .._., TYPE,, CABLE REPLACEMENT i Pole NT(across from driveway) E HOUSE# . .Lock Bok...._. - - .., eoKCovetNadaMptieainoritt.`' - 1 I la them a TEMP cable in lace at this U.? YES Flo! 325 Dees oras el, 750'total reywro a ROAD cure YES Fro: ' - DRIVEWAY SHOT ,YES rC DiWEWAYS 2 CON':UCTIONTYPE , UNDERGROUND' CABLETYPE: 50OP3 FOOTAGE Depth- CONS this a house drop? NO What is the drop length? Is there a spare cable? NO Is the drop Aerial or UlG7 Underground YES Needs new underground from Riser pole(diagonally across street)to terminating 7 tap In pad by house 1405 Flit)ngs and equip.been changed? Ackerly Pond Ln.Cable has fault 642 feet from ped,56 feet from riser pole.Levels dropping on high end digitals (747).Crosses 2 driveways and 1 roadway.750 feet 5DO p3 needs replacement Temporarily rerouted cable to be Is this a dangerous situation? NO Comments: fed from term 7 tap before customers pod.Would like cable replaced as par design.OSP wilttle in. SIGNAL LEAKAGE MEASUREMENTS C.L.I.Level @ 10 feet before repair meas, tooatbn and,.palrot leak heb-2e.wm If leak Is generat4d from plant identdy the approx.WeJbon of Homo Tap WOP Faod.r TrunY the leak a document of Infomution on this foml. C.L I.Level @ 10 feet after repair meas. Pad Value(ifused) ola hVP _....,. .DESIGNAEFERRAL All desi n rare Pals must have takeoff Coles and rootages,Drawlno must have exact location of cable drops and feeder If needed Third party Damano Information ., ' Tech 1! Time worked 1s Terh 1 2nd Tech 3id Tech i , see Attached 1 (Construction Use Only) Dato'Racehfed::; _ ",a:.' =TecheiContractor.ass nedto:.a.: _' 75ate791gned:77 7.7 -NCR(not con4trelated) NCR•Given Back To; NCR•Date:Given.eack:. L. 1 i Actual,Comp:Date:;. ,� ; . Tobh(s}l,CoitWectoirwhd.completed the work ";CompleUtm Coda, Construction Completion Comments: Needs Activation YtN 'nCR rcounse wmsmenl !i f i i z f i masWorld ((� # NT +� i °P �* X9B112-0A NT o � DF .� • 9 • � t � y . + • + I o • • 4 � I ♦+ ♦ • + P t , � + ♦ 1 � • r V 20 m 50 Zf• R,C _ Map data©2020 i I G t C