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HomeMy WebLinkAboutHenrys Ln rmitNo._ �� TOWN OF SOUTHOLD Lam' �suFr:ol,�c�. HIGHWAY DEPARTMENT Peconic Lane 5 Peconic,New York 11958 S"o (6-31)765-3140 �a APPLICATION/PER1<91T FOR 111G]INVAY EYCAVATiON 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 Yoik,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 Type 1. ce— CokzyI 1dn Name of Applicant Phone Number Address of Applicant 2. Ct�L- li�icS� .eyi� Lp31-2la-atS2 U1 w. Te.6010 SI-C (nC,_ NW117st'7 Name of Contracts Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable) Address of Owner a. KIS)(:) kfMN S Lal. -7140 hov�e5 //70, AS-M, 11P . le 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 Signature of Applicant Application/Permit Form is Required for a complete application! Ql? ZaZ 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. G. Tax Map No.: District 1000 Section Block Lot 7. Starting Date: 1?,sI Z1 Completion Date: gJ2g120z i S. Work Schedule: Phase Completion Date Excavation Work Schedule Facility installation Must be provided Backfill S Completion 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. 10. Estimated Cost of Proposed Work: S J / II. Remarks:�� 7heu�Ha/7L /Yl/551 - 1— �4hG �S �D 1nSr// �9�5 C)f D-39 1 of 5 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: (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$2,000,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. 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 $ r 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. Utility Repair Excavations @$1,000.00/Each $ No. Additional Repairs of Same Service @$500.00/Each $ No. TOTAL$ /}�-' `� V 7) 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: n accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if a y)attached hereto. SUPERINTENq T O G TOWN OF SO D W Vindent . r a I� Date Date Received by the Town CIerk � Date Permit Issued -1 9'0 194 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 S Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified I St 2nd 3rd 4th (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 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 5 -,-a- W 1 L 8 n � l 2 A`R ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/14/2021 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 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 Obede Risk Strategies, LLC PHONE — FAx 14288 Manchester Road No. o E •636-391-0700 A/c Noy 636-391-0715 Manchester MO 63011 E-MAIL : donna.spradley@obefle-risk.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:TRAVELERS IND CO 25658 INSURED CDLUN-1 INSURER B;PHOENIX INS CO 25623 CDL Underground Specialists, LLC 821 W Jericho Turnpike INSURER C:Starr Indemnity&Llab Co 38318 Suite 6-7c INSURER D:NAVIGATORS SPECIALTY INS CO 36056 Smithtown NY 11787 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:337901968 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. INSR I ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER MM/DQr EFF MM/DD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY Y C05R353463IND20 925/2020 9/25/2021 EACH OCCURRENCE $2,000,000 CLAIMS-MADE ®OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $300,000 X Contractual MED EXP(Any one person) $5,000 X XCU Included PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 X �PRO- POLICY F LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER $ A AUTOMOBILE LIABILITY BASR3473522026G 9252020 9252021 COMBINED SINGLE LIMIT Ea .,d.nt3 $1.0D0.000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident AUTOS AUTOS ) $ X HIRED AUTOS LX NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ C UMBRELLA LIAB X OCCUR 1000586586201 9252020 9252021 EACH OCCURRENCE $3,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $3,000,000 DED I I RETENTION$ $ B WORKERS COMPENSATION UB5R352558 925/2020 9/25/2021 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE E L EACH ACCIDENT $i'Coo,000 OFFICER[M(Mandatory In ER EXCLUDED? ® N/A E L DISEASE-EA EMPLOYE $1,000,000 (Mandatory In NH) If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT 1$1,000,000 D EXCESS LIABILITY($2m xs$3m) NY20EXCZ06DRMIV 925/2020 9/25/2021 EACH OCCURRENCE 2,000,000 GENERAL AGGREGATE 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Town of Southold Is an additional insured as regards general liability if required by written agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 275 Peconic Lane AUTHORIZED REPRESENTATIVE Peconic NY 11958 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD