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Home My WebLink About180 Summit Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 07/14/22 Receipt#: 303527 Quantity Transactions Reference Subtotal 1 Excavation Permits 1591 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#6467 $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: 1591 Sq nn,, Permit No. q t RECEIVED S TOWN OF SOUTHOLD oS11E01,�E, HIGHWAY DEPARTMENT JUL 1 4 2022 Peconic Lane Peconic,New York 11958 r g (631)765-3140 Southold Town Clerka1 ' ` 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 Tune 1. � � �'�Kee Um e1 �cr�rx� U�r<< i es % - 'Galt 01� 2d- 2ic�9.e. MY. 1196/ If Name of Applicant Pho a Number Address of Applicant 2. Zo 31- q8-/- Stela /arab/a A yah 0,co,-J77-5-- Name of Contractor Phone Number Address of Contrac or 3. Far. Otabl.eU( Slon Name of Property Owner Requesting Service(if applicable) Address of Owner 4. Q— aCe s an Fromm QJ s l� of �l�U sc)r4n-' -� t1l � � S(� CCF Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlan s. *Yes No *If yes,other Town permits may be required. nn nn NOTE: All information requested by this U Signature of Applicant Application/Permit Form is Required for a complete application! 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 Block , Lot (Q .'s 7. Starting Date: Completion Date: . s 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: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ 11. Remarks: f D-39 1 of 3 a ' 12. Insurance Coverage:(Attach Copy) / (a) Insurance Company: }-�Crl.-��-i �J Cqr1 S�n d 604- Vim/ (b) Policy ff: (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 erformed:$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. ys5� re- \-P,,I�. /Service Connections excavations @$50.00 $ SD_Cr korl�So. 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 ofExcavation; 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$ 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 TO OF SOUTHOLD,NEW YORK 1AVIELT,000,bM0 Date Date Received by the Town Clerk ' 1- 2 2 Date Permit Issued I - I LI- _Permit No. 5 l 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: Permit# � S-Q` ' Highway Department r Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified ls` 2nd 3rd 4a' (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 WP 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 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIYYYY) AC D® `.� 05102/2022 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 WANED,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 endorsements). PRODUCER NAME: William(Will) Fontaine Bay Harbour Ins Agency, Inc. AIC N Edj- . (631)758-1550 77712,No):(631)2139 2176 88 Waverly Avenue ADE DRESS; service@bayharbourgroup.com Patchogue, NY 11772 INSURER(S)AFFORDING COVERAGE NAIC;V INSURER A: Evanston Insurance Company INSURED INSURERB: Century Surft Company Joe's Underground Utilities Inc INSURERC: 8 Gull Dip Road INSURERD: Ridge, NY 11961 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 000025714067719 REVISION NUMBER: 1 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 CONTRACTOR 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 TYPE OF INSURANCE ADOL SUER POLICY EFF POLICYEXP LIMITS D POLICY NUMBER MMIDD MID A X COMMERCIAL GENERAL LIABILITY 3FF1322 04/29/2022 04129/2023 EACH OCCURRENCE $ 2.000,000 —1DAMAGE To-RENTED CLAIMS-MADE FRI OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X JEC T LOC PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY 1:1 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LM-Ir $ Fs accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNEDPROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident B X UMBRELLA LIAB X OCCUR CCP1062069 04/29/2022 0412912023 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER-------7-70TH. AND EMPLOYERS'LIABILITY YIN STATUTE I I ER ANY PROPRIETORIPARTNER/EXECUTIVE ❑ N/A EJ_EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Ii es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if mora space is required) Installireplace CATV Lines and or conduit CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Rte 25 Po Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTA__TWEE kt{few&h WF1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) o The ACORD name and logo are registered marks of ACORD Printed by WF1 on 05/02/2022 at 11:38AM NYS' I F NawVarkSatoinsur. Fund PO Box 88899,Albany,NY 12206 nysft.com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE AAAA^" 331212677 SPECIALIZED INSURANCE& SERVICES INC 204 ROUTE 112 ml o.Sl PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JOES UNDERGROUND UTILITIES INC TOWN OF SOUTHOLD 8 GULC DIP ROAD 53095 ROUTE 25 RIDGE NY 11961 PO BOX 1179 SOUTHOLD NY 11958 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12157309-2 740786 08110/2021 TO 08/10/2022 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$09-2, 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 NEIN 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:INVWW.NYSIF.COM/CERT/CERTVALASP.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 JOES UNDERGROUND UTILITIES INC (ONE PERSON CORP) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGlt= UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER 1 THE COVERAGE AFFORDED 13Y THE POLICY. NEW YORK STAT SU NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:275806090 U-26,3 W ' NOEW rkers CERTiFtCATE OF INSURANCE COVERAGE 1frA7woe 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 UNDERGROUND UTILITIES INC 631-484-8512 8 GULL DIP ROAD RIDGE,NY 11961 1c.Federal Employer Identification Number of Insured Work,Locatlon of Insured(Only required ff coverage fa apeclfkally limited to or Social Security Number certain locations in New York State,i.e.,Wrep-Up Poky) 331212677 2.Name and Address of Entity Requesting Proof of Coverage 3a.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 oil all PO BOX 1179 DBL260677 SOUTHOLD, NY 11958 3c.Policy effective period 09122/2021 to 09/21/2023 4. Policy provides the faitowing benefits: ® A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: A.All of the emptoyer's employees eligible underihe NYS Disability and Paid Family Leave Benefits Law. 0 B.Only the following class or classes of employer's employees: Under penally of perjury,I certify that I am an authorized representative or licensed agent of the Insurance car er rVerenced above and that the named insured has NYS Disability andlor Paid Family Leave Benefits insurance coverage as described above. 3/28/2022 Date Signed By r (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 5B 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 malted 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 sox 4B,ac or ss 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 NY5 Disability and Paid Fatuity Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date;Slgned By (Signature of Authorhrd NYS Workers'Compensation Hoard Employee) Telephone Number Name and Title Please Note:Only Insurance carriers licensed to write NYS disability and paid farnily leave benefits insurance policies and NYS licensed Insurance agents of those insurance carriers are authorized to Issue Form DB-120.t.insurance brokers are NOT authorized to Issue this form. - DE-120.1 (12.21) �IIIIfPD�"�II1II2��0 II��1 (�12�-12�1 �lllp i 6 Joe 's Underground Utilities Inc . Joe Robson 631-484-8512 8 Gull Dip Rd.Ridge NY 11961 Larobl2@yahoo.com Fax-631-775-6511 For Cablevision # sCo�v(D�yy� Cx LO cJs G,)s j 180 tz ti � x p 6 (3a eo s t jo- OF !so l� �� OF �3v \ U I� �- C,jo-v� O YC- L2v 5 ��