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Home My WebLink About103 Fleetwood Rd Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 05/20/21 Receipt#: 281076 Quantity Transactions Reference Subtotal 1 Excavation Permits 1485 $55000 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#4202 $550.00 Patriot, Contracting Corp Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Patriot, Contracting Corp Po Box 548 Southampton, NY 11969 Clerk ID: LYNDAR Internal ID. 1485 Permit No. TOWN OF SOUTHOLD o�g%3FFQj/r r HIGHWAY DEPARTMENT Peconic Lane y Peconic,New York 11958 c (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 Tvne 1-. Name of Applicant Phone Number Address of Applicant 2 Patriot Contracting Corp 631-283-2240 PO Box 351, Westhampton, NY 11977 Name of Contractor Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4 Directional bore from pole to 103 Fleetwood Rd for new electrical conduit Work Description and Location(Street Number,Hamlet,Cross Street) x (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes;other Town permits may be required. billing@patriotcontractingcorp.com 631-283-2240 NOTE: All information requested by this Si of Applicant Application/Permit Form is f Required for a complete application! La / 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 13 7 , Block 04 , Lot 008 7. Starting Date: 5/17/21 Completion Date: 5/17/21 8. Work Schedule: Phase Com letion Date Excavation Work Schedule Facility Installation 17 T21 Must be provided Backfill&Completion for consideration as a Pavement Replacement 5 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: $ 3000.00 11. Remarks: work being done for Peconic Power Services D-39 1 of 3 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: Farm Family (b) Policy#: GL# 310 2 X 1171 WC# 310 3 W 7 4 3 3 (c)State whether policy of certification on file with the Highway Department: attached (d)Coverage required extended to the Town: <k- ivu.�i iuvi'Mviu -OCIII` — ---4-,v i- ua —al iu au vi'--v` yr ui�u bui liie w+.ruiv iivi�a aa"".aavu: 7 b J'uJ .1 Y` Y `l ' J .1 J $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. F GCS 1Ur App11G611uns Unu PURM 3: 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. a, 50 hl. OG1viuc%-U"UVULLUM VAulvauuum lW.pJV.vv .p No. A2. 0 /Additional Excavations same service @$20.00 $ No. B. Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; 0 L.F.@$10.00 $ C. Trench Excavations 18"in depth to 5'in depth Total Lineal Footage of Excavation; 0 L.F.@$30.00 $ D. Trench Excavations 5'in depth and over Total Lineal Footage of Excavation; 0 L.F.@$50.00 $ Q n A� 000A. E. Uunty Repair Excavations @$1, 0.00/Each No. 0 Additional Repairs of Same Service @$500.00/Each $ No. TOTAL$ 550.00 F 0 it;a1 ATM4— Ho t rmr;,I.A.-A 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 r this application and subject to the"General Conditions"and"Special Conditions"of permit(' any)attached hereto. SUPE TE ENT F HIG S / TOWN OF S O , v intent M.yr Date Date Received by the Town Clerk 4 401 Date Permit Issued 620ortPermit 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: '' rr Permit# j `C $S Highway Department Engineer(with page 3) Applicant Town Clerk(uriginai) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1st 2nd 3rd 41' (To Permit Clerk) REMARKS CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due to backfilling) BUC Building Under Construction W2 w uric in process DB Improper Backfill(too high,not sufficient) HF$ Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 4 -Pcdf-�(4 ccs a ko cc�r (os�r a�,S- �\0 l !�� 0 �� v 4m Et otj SC-' �S 14, 300 eAwo)o6 l-- N'R41vv 0 rG- 4 �t� � ')•F•r��' ! _ ' _.,X31 h��^ �,..e�,.,_ t 3 rr•�.xiwn:v `' �ie�wern•••.rr+ns>r. _ 41 1 `K -- r; rH Xlor ._f U � 4 v, At P 71W 10 AV Al lk my 4 0 } b "�F�^� LVk A�`ha.'ftr±Y LF .' y' 'yP� :•R� �'. _ _.—��_. :: w � � A �• a E�� S-! rc+'C: ._�� 1 eet -adRd z � 25 MO DATE(MMIDDNYYY) 05/03/202 A R CERTIFICATE OF LIABILITY INSURANCE '1--_--_ 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 pollcy(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 --=•thls-certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ONTACT NAME: Matthew Dale Farm Family Insurance PHONE . 631-744-3350 Af No): 631-744-3383 85 Echo Ave-Suite 2 &DORESs: matt.dale @farm-famil .com INSURERS AFFORDING COVERAGE NAIC# Miller Place NY 11764 INSURERA: Farm Family Casualty Ins Co 13803 INSURED— INSURER B: Patriot Contracting Corp INSURER C: PO Box 351 INSURER D: INSURER E: Westhampton NY 11977 1 INSURER F: 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 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. ILA DLS BR POLICY MD TR TYPSOFINSURANCE POLICYNUMBER MDPOLICY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 110001000 DAMAGE TOR NTED _ CLAIMS-MADE X OCCUR PREWSES Ea occurrence $ 100,000 A 3102X1171 07/12/2020 07/12/2021 MED EXP(Any one person) $ 5,000 PERSONAL$ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X RD LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY❑PE OTHER: 1 $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ accident 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 _ $ A UMBRELLA LIAROCCUR 3101E3776 07/12/2020 07/12/2021 EACH OCCURRENCE $ 5,000,000 -— -®(CESS LIAR HCLAIMS MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATIONX SPER TATUTE ETH- B AND EMPLOYERS'LIABILITY YIN 3103W7433 01/17/2020 01/17/2021 OFEOPPEBEARNE/EECUTIV= NIA ELFACHACCENT $ 11000,000 FCiMMRE (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD-161,Additional-Remarks-Schadule,may be attached if more apace-is required). CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Main Rd THE ACCORDANCE EXPIRATION NOTICE WILL BE DELIVERED IN WITHTHEP CYPROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(20161031 The ACORD name and logo are registered marks of ACORD � NTATEW Workers' CERTIFICATE OF SE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of Insured (use street address 1b. Business Telephone Number of Insured onl ) (631)283-2004 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, 1c. NYS Unemployment Insurance Employer Registration i.e., a Wrap-Up Policy) Number of Insured PATRIOT CONTRACTING CORP 1d. Federal Employer Identification Number of Insured or PO BOX 351 Social Security Number: WESTHAMPTON;NY 11977 94-3462006 r "i 2. Name and-Address of Entity Requesting Proof of 3a. Name of Insurance Carrier - - Coverage United Farm Family Casualty Insurance Co. (Entity Being Listed as the Certificate Holder) -; 3b. Policy Number of Entity Listed in Box"1a" _TOWN OF SOUTHOLD 3103W7433 53095 MAIN RD SOUTHOLD, NY 11971 3c. Policy effective period 01/17/2021 to 01/17/2022 3d. The Proprietor, Partners or Executive Officers are o included. (Only check box if all partners/officers included) o all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1a"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the 'workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". 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 end of the policy effective period? x❑YES []NO This-certificate is issued as a matter.of information only and confers no rights upon the certificate-holder.-This certificate.does.notamend,-extend-or -. l alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. .i ! 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 authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' --Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured hasthe coverage as depicted on this form. r 1 ,ice '-" pproved by: Matthew Daley ' (Print name of authorized representative or licensed agent of insurance carrier) Approved by: May 3,2021 (Signature) _ (Date) Title Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-744-3350