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Home My WebLink About260 Halls Creek Dr Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 04/06/22 Receipt#: 296159 Quantity Transactions Reference Subtotal 1 Excavation Permits 1565 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#6287 $550.00 Joe's, Underground Utilities Inc. Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Joe's, Underground Utilities Inc. 8 Gull Dip Road Ridge, NY 11961 Clerk ID: LYNDAR Internal ID: 1565 Permit No. 565 RECEIVED TOWN OF SOUTHOLD o�SUFFO(,rco HIGHWAY DEPARTMENT Peconic Lane ' APR - 5 2022 Peconic,New York 11958 oy (631)765-3140 Southold Town Clerk 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 1. _��5 Un�rc(rUy►'1� U� �l+l�S �n� Name of Applicant Phone Number Address of Applicant 2. 3c &56n - �3/-y�'y-�ss�a - a 6011 ),p Name of Contractor Phone Number I- Address of of/Contractor 3. �31 A Loc i Name o Property Owner Requesting Service(if applicable) Address of Owner 4. T'rom UltcrI art NQSh:2CsF JL0 (,W15 Crete Dr - cUrjer PeLJ S49K-ft00 Work Description and Location(Street Number,Hamlet,Cross Street) p d le cro N (a) is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. Ree— j NOTE: All information requested by this Signature of Applicant Application/Permit Form is Required for a complete application! 3' 2-7-a- 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 ,J Block Lot 7. Starting Date: 8t f1G x'31 %�� Completion Date: 3aryw-. 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. 9. Under which authority is application being made: 2C J1 l OY% See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: 1$ 11. Remarks: (S Cry S�crw-s l35 re UCc � . i Cv1" 15 I�I C2 'C�.UV� �J I eco I n c f oJe .�1cptal r- +-6e- J&f 15pOfj CA(onq(0)s rdx- D-39 - 1 of 3 12.. Insurance Coverage:(Attach Co 'y) (a) Insurance Company: 1!�� Ch� - c�Ci✓LST�/r L. (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 $ <-->C) , No. 2. /Additional Excavations same service @$20.00 $ le No. �55L Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; L.F.@$10.00 $ r � 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. ,� I TOTAL$ �� l6/ 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)attached hereto. SUPERINTENDENT OF HIGHWAYS TOWN210t OLD,NE�WY7RK Date Received by the Town C er1 4 Date 5 .L Date Permit Issued Permit No. 15 C�5 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: C / Permit# J(O Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1st 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 3 foe, pct ro �cjr Cab leui sl on c qo New So(To K Ne v V-r-ola col I , ,-Q A'C-YV— V) j4-tpo ti -*Dr(pr(Laj-e-Y un AxV, 4— � ��Prve Ljp �Lt (COO CICIIJ �tEQ`TWICATE OF LOAMLIT[I INSURANCE DATE(MM@DIYYYY) 03/28/2022 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the tens 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 C ACT lay F larbOur IriSUranGe _ __ _ rdAME: Bay Harbour Ins Agency, Inc. N >R: 631 758-1550 a�N.):(6311289-2176 88 Waverly Avenue A DRESS: service(a)-bayharbourgroup,com Patchogue, NY 11772 INSURER(5►AFFORDINGCOVERAGE NAILI$ _T INSURERA:Evanston insurance Company 35378 INSURED INSURER 13Century Safety Company 36951 Joe's Underground Utilities Inc INSURER C: 8 GUII Dip Road INSURER D; Ridge, NY 11961Fliw.'SURERF: SURER E: !^ 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. _ IL SR TYPE OF W6URANCE ADD SUB R POLICY EFF POLICY EXP ^ POLICY NUMBER MMIDD0= (MMIODNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY Y N 3FA9962 4/2912021 4/29/2022 EACH OCCURRENCE s2,00-0,000 AMAGE—1CLAIMS-MADE EJOCCUR PREM SES EnEocccurrefi� nice — $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY❑PEO LOC PRODUCTS-COMPIOPAGO s4,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMrr $ _(Eaaccident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ ALTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _ S AUTOS ONLY AUTOS ONLY (Per acciden[Z_ UMBRELLA LIAB OCCUR Y N CPP973540 4/29/2021 4/2912022 EACH OCCURRENCE $1,000,000 X1 EXCESS LIAIS CLAIMS-MADE AGGREGATE $1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILI Y YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDEDZ NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L,DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E,L,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 10i,Additional Ramaft Schedule,may be attached if more apace is required) Install, repair, replace CATV Lines, install conduit. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11958 Kamy., c e c e WF1 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by WF1 on March 28,2022 at 11:23AM 4TA"'W Workers' CERTIFICATE OF INSURANCE COVERAGE TE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that Carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured JOE'S UND ERGROUND UTILITIES INC 631-484-8512 8 GULL DiP ROAD RIDGE,NY 11861 1c.Federal Employer Identification Number of Insured Work Location of Insured(only required if coverage!s specif tally limited to or Social Security Number certain locations In New York Stale,Le.,Wrap-tip Policy) 331212677 2.Name and Address of Entity Requesting Proof of Coverage $a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 53095 ROUTE 25 3b.Policy Number of Entity Listed in box"1a" PO BOX 1179 DBL260677 SOUTHOLD. NY 11958 3c.Policy effective period 09/22/2021 to 09/21/2023 4, Policy provides the following benefits: A.Both disability and paid family leave benefits, C] B.Disability benefits only, C.Paid family leave benefits only. 5. Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] B.Only the following class or classes of employer's employees: 1 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 NYS Disability and/or Paid Family Leave Benefits Insurance coverage as described above. AW/Qate Signed 3/28/2022 By (Signature of Insurance carrier's authorized representative or NYS licensed Insurance Agent of that Insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer IMPORTANT: if Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mall It directly to the certificate holder. If Box 48,4C or 59 Is checked,this certificate Is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS i Disability and Paid Family Leave Benefits Law.it must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 6200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only If Sax 48,4C or 5B have been checked) ! State of New York Workers' Compensation Board According to Information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Warkers'Compensation Board Employee) Telephone Number Name and Title Please Note;Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-920.1.Insurance brokers are NOT authorized to Issue this form. i DB.120.1 (1221) DB-120.1 (12-21) NYSIF New York state Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE n n n n n n 331212677 SPECIALIZED INSURANCE& , SERVICES INC 204 ROUTE 112 #.mw PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JOE$UNDERGROUND UTILITIES INC TOWN OF SOUTHOLD 8 GULL DIP ROAD 53095 ROUTE 25 RIDGE NY 11961 PO BOX 1179 SOUTHOLD NY 11958 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12157309-2 740786 08/10/2021 TO 48/10/2022 3/28/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO, 2157 309-2, 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, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:INVM.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION, JOSEPH ROBSON(PRES)OF JOSS UNDERGROUND UTILITIES INC (ONE PERSON CORP) 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, I i I i NEW YORK STATE SU NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:275808090 U-26,3