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Home My WebLink About245 Kimberly Ln Town of Southold P0Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 08/06/21 Receipt#: 285852 Quantity Transactions Reference Subtotal 1 Excavation Permits 1500 $500.00 Total Paid: $500.00 Notes: Payment Type Amount Paid By CK#10864 $500.00 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 1500 ermit No. t � TOWN OF SOUTHOLD ��5111FFOf,��o HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 0 (631)765-3140 4& APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR PLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit pi rsuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or re lations for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws, or inances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized in pectors to make necessary inspections of the job site. P .nt or T e 1. l w\6, v��c��e�, Q,abJ6V ISl®Name of Applicant Phone Number Address of Applicant i AI 6LI cG e,S' . 2. Cer��fr \S\0!nJ �\_ 5 05 n �Y ) u Name of Contractor Phone Number Address of Contractor —7 3. 2- 4S LAI-16 , sou4h C5 OA Name of Property Owner Requesting Service(if applicable) Add ess of Owner 4. a44c 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. NOTE: All information requested by this ature of Applicant Application/Permit Form is Required for a complete application! �p Z 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. J 6. Tax Map No.: District 1000 . Section Block ( r , Lot a0 •9 7. Starting Date: 'A SA� G.. Completion Date: d n Li . 8. Work Schedule: Phase Completion Date Excavation Qq 1 Work Schedule Facility Installation -0Q\J \ %-2 Must be provided Backfill&Completion Mxvo 1 -t for consideration as a Pavement Replacement &i &Li1 p®Ch&7 Complete Application. 9. Under which authority is application being made: �Pf-Y?it- 11''f Ci(-eM&rl See Town Code Chapter 237(E)-Provide Resolution by,or authority frm,the Utility being modified. 10 Estimated Cost of Proposed Work: $ 11 Remarks: D 39 1 of 3 11 Insurance Coverage:(Attach CoQpy (a) Insurance Company:—A$' o n+ , C— f S LV I h i S . C_CJm lean l (b) Policy#: 2 (Q 100 Y-(a-5 (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$2,000,000 general aggregate. 1 . Security: CO b1 eV�5�W)(a)Surety Bond Cin, V71 e -or Certified Check provided in the total Amount of$ (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. 0_/Service Connections excavations @$50.00 $ o. 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. 0 Utility Repair Excavations @$1,000.00/Each $ Ngo, (� Additional Repairs of Same Service @$500.00/Each $ No. �1 �-\ TOTAL$ �1�0 o O V 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(if any)a ched hereto. SUPERINTENDENT F HIG WAY TOWN OF SOUT D,N %cent .Orlando,,/ / 1 Date Date Received by the Town Clerk Date Permit Issued6 [WQ N Permit No. Sob 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 �,�fi � THIRD PARTY CLAIM/Form Number: Referral Form DAMAGE NQ REFER TO: CONSTRUCTION ETS I Remedy Ticket: DSTX00138847171 Facility/Dept Rivelrhead OSP Supervisor D.Greene Tech#/Cell# 2236 Luigi 516-779-1076 REASON FOR WORK 1. - DAMAGE REASON 2 CLI Pole PS Amp Tap DESIGN INFO ONLY DESIGN Design Type TYPE 1 2(Recomm) Residential Existing I New Subscriber Existin Repair Location: j 230 Kimberly Lane _ CORP 7639 Account 317254-01 Date April 22,2021 Name Alexande Koke Phone 631-765-1607 Grid/Map Address: 245 Kimberly Lane X-Street Pine Neck rd Town: Southold i Hagstrom _ (include TDR printout'if cable_replaeement_is needed) CorpHeadend Node CH2 CH70 CH119 603 MHz 693 MHz 747 MHz I X9B112 Tap Pre-Fault Spliced Point: Ground Block: ' Tap Post-Fault Aerial Work(list polebenumbe nearers)&, TYPE CABLE REPLACEMENT ` st house an rs) POLE HOUSE# ��'LOCk BO%• Box Cover Needs Replacement. Pedestals 4 30 feet Is there a TEMP cable in lace at this time? YES Ftg, no Does the repay require a ROAD CUT? YES Ftg• DRIVEWAY SHOT YES #OF DRIVEWAYS 3 CONSTRUCTION TYPE UNDERGROUND CABLE TYPE 625 FOOTAGE 480 feet Depth Is this a house drop? NO What is the drop length? Is there a spare cable? NO Is the drop Aerial or U/G? Underground Fittings and equip been changed?YES Comments NO Is this a dangerous situation? -SIGNAL LEAKAGE MEASUREMENTS ' C L I Level @ 10 feet before repair meas Locahon and repalr of leak eabme 20uV/m N leak is generated from plant identify the approx location of Home Tap Drop —.rL_l Trunk the leak and document of information on this form. C L I Level @ 10 feet after repair meas Pad Value(d used) Dispatch V# DESIGN REFERRAL All desl n referrals must have takeoff poles and foots es Drawing must have exact location of cable drops and feeder if needed Third party Damage information Tech# Time worked 2 new spans of U/G feeder needs to be ran. 1st Tech 1st span is 260 feet,from output of DC7 on LIPA pole 2nd Tech 40 on Pine Neck rd to input of LE by house 230 Kimberly Lane. 3rd Tech 2nd span is 220 feet,from output of LE to input of 20 tap by 245 Kimberly. Y C1hed Fault on feeder is in the middle of driveway of house See ptta 245 Kimberly. ' (Construction Use Only) Date Received: Tech(s)/Contractor assigned to: Date Assigned: -,*,NCR(not constrelated) NCR-Given Back To; =NCR-Date Given Backe Actual Comp.'Date: - ` Tech(s)/Contractor who completed the work- _ `Completion Code " Construction Completion Comments: Needs Activation Y/N NCR requnes comment W ®® lain 1&2 4 aisl p j 3 9 ns O r ` 8 N23si9t� #z# 1 �- � 2 new spans of U/G feeder needs to be ran. .— '�t 1st span is 260 feet,from output of DC7 on LIPA pole 40 on Pine Neck rd to input of LE by house 230 Kimberly z`.+ as Lane. 57 � N2EHLB1IOU � � _ 2nd span is 220 feet, from output of LE to input of 20 tap O 38 t Ti--W--- - -- by 245 Kimberly. psis ' y IL C�7 `, Fault on feeder is in the middle of driveway of house 245 X• �"� 1 Kimberly. loom 1 10.7 ` 51 r•�. Center Island Services ® �� ®/,0 erg 67 Sycamore Street , Patchogue, NY 11772 Office: (631) 475-5600 Fax: (631) 475-8830 Contact: Sal Cipolla- Cell: (631) 774-8599 Cablevision Projebt#: 76 9/6 o J_ -7 7_ ------------------ V/9 _T_ T--T----7- - - IslandVenter,- S cervi es I o 67Sycaoret I -Patchogue,-N__ - - 7-72' icer((6jl) 475=560Q ----------- -------- Fax. 31 -Contact:- alFCipolla-— Cell: (631 ) 774-859 Cablevision ct Proll I,76-NO Project _—F j- ID 00- T' ----I CERTIFICATE OF LIABILITY INSURANCE DATE(MM,'DDIY.YYY) 1012o/zo20 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. t cert catso ars an A1515MUNAL INSURED—,the policy(les)must be endorsed. ,su Det 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 ondorsement(s), PRODUCER UUMAGI NAME. "'iII13mF.SCha3ke PHONE rm( Group Coverage Inc. A1C No EKt• 516-3968275 A1C,No: 516.576-0909 PO Bore 480 ADDREss: bill@_groupmveragt.net 516-578.0007 INSURERIS)AFFORDING COVERAGE MAIC A West!slip NY 11795 INSURER • Atlantic Casualty Insulanoll Company 21792 INSURED INSURERB: MGM lnsuranceCompany 14788 Center Island Sorvices,Inc. INSURERC: HARTFORD ACCID&IND CO 22357 67 Sycamore St INSURER D: INSURER E: Patchogue NV 11772 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREM+JENT,TERAS 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.LI164ITS SHOWN MAY HAVE BEEN R��EppDUCED BY PAID CLAIMS AD1JVSUB �""� TNSR`� INSD 11+1VD POLICY NUMBER 1(MMIDDIYYYY1 1 awmC rECP- TYPEOFINSURANCE YYYYI 1 LtMrrs LTR x I COMMERCIAL GENERAL LIABILITY EACtI00CURrfEWCE 5 5560.000 CLAPP.SA(ADE I.1 OCCUR PREMISES 1 E a awwresleel $ 50.000 MED ESXP JAny a m penan) Is 5.000 A 1261004365 1010312020 10+0312021 PERSONAL a ADv LvjLrRY is 5.000.000 GENLPIGGREGATEIJMITAPPLrSPER: GrKERAL AGG REG ATE 5 5.000.000 it POLICY D JCT LOC- PRODUCTS-COMPh0P AGG 5 5.000.000, OTHER: 15 AUTOMOBILE LIABILITY XTacxides,I► vLM 1 $ 1.000.000 X ANYAUTO BODF.Y MURY(P&pe=o) B AAM OVXED �SCOS DULED BIU4384Y 10/0312020 1Q10312021 BODILY WURY 1Persoddentl $ X HIRED AUTOS �OOS�,7nm S'Pets9W.1/' S 5� UMBRELLA41AB I 10=, FACHtOWURRLNCE !$ EXCESS LIAB I CLADAS-WIDE AGGREGATE S DED d 1 RE.ETssWION 5 S WORKERS COMPENSATIDNJkt- AND EMPLOYERS L ABILITY YIN STATUTE I I ER_ ANY PROPRIERME TOlPARTNEXECUTNE E L.EACHACCI�3EN'r 5 1.000.000 C OFFICERIMEMSEREXCLUDED7 NIA 12W�:AAOKYM 03121/2020 0312112021 IMamiatmry im NTTi E.L.DIS:ASE-E,k E.MoY $ 1.000.000 Ir e3,de�eee ends D�CRIPTfteN OF OPERATIONS LKAON f g E L DISEASE-POUCYL(IT(5 1.000.000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES(ACORD 1®1,Additiamar Remarks Schedule.my he attached if nwe®pace Is taquiradJ Certificate isevidence of insurance for the named i nsured,s ubjoct to terms,conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN T0lvnof Southold ACCORDANCE WITH THE POLICY PROVISIONS. 275 Pecor iC Lane AUTHORIZED REPRESENTATIVE PoniC NY 11958UrClftrri�uf�� I 0 1 938-201 4 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo aro registered marks of ACORD NEW Workers' SYORK TATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal'Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Center Island Services Inc. 631-475-5600 67 Sycamore Street 1c.NYS Unemployment Insurance Employer Registration Number of Patchogue, NY 11772-2874 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i e,a Wrap-Up Policy) Number 11-3436332 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Twin City Fire Ins. Co. Town of Southold 3b.Policy Number of Entity Listed in Box"1a" 275 Peconic Lane Peconic, NY 11958 12WECAK9DRY 3c.Policy effective period 03/21/2021 to 03/21/2022 3d.The Proprietor,Partners or Executive Officers are Included.(Only check box if all partnerslatficets included) ® 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"1 a"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". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does It confer any rights or responsibilities beyond those contained in the referenced policy. 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 has the coverage as depicted on this form. Approved by: Nicholas Devito (Print name of authorized representative ortitans agent of i surance/tamer) Approved by: (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-509-6388 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to Issue It. C-105.2(9-17) www.wcb.ny.gov