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HomeMy WebLinkAbout7940 Indian Neck Ln & 7055 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 12/27/22 Receipt#: 307355 Quantity Transactions Reference Subtotal 1 Excavation Permits 1623 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#1785 $550.00 CDL, Utilities Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: CDL, Utilities 821 W Jericho Tpke Ste. 6 C Smithtown, NY 11787 Clerk ID: JENNIFER Internal ID: 1623 6 Permit No. _ I A 117 , TO'W-N OI' SOUTHOLD RECEIVED HIG1-IWAY DEPARTMENT Peeonic Lane Peconic, New York 1 1958 a DEC 2 7 2022 (631)765-3140 APPLICATION/PERMIT FOR TlIGUWAY EXCAVATION AND REPAIR So )PI- CAT UN' �1�� , PPL (I 1 ( N I- -} ' made to the Superintendent oft lighways 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 Count},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 T\AL,.� I. Name of Applicant Phone Number Address of Applicant 2. �----V ����5_ _ 1rv31214 9152 B2( !�J•.J*-�icho J�I� 5 -�C Sr�nt;►Mt N� �17a�� Name of Contractor Cy eV Phone Number Address of Contractor 3. �-- — Name of Properly Owner Requesting Service(if applicable) Address of Owner a. ir�sf�IL� y5 a C,4C"do'— 1:161p houses 79A) r 7055 -�%Ylc a�J�e�i� L►-� __. 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. z r'4z NOTE: .All information requested b}'this Signature of Applicant Application/Perrot Form is Required for a complete application'. 12' ZZ 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 license's for this project. (c) Work covered by this application may not commence before issuance of a Highway Excavation Permit by the Town Cie k. 6. Tax N,Iap No.: District 1000 Section Block 7 Lot 7. Starting Date: 17,'Z1— ZO?,-Z- Completion Date: S. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation ;lust be provided Backfill S-, Completion for consideration as a Pavement Replacement Complete Application. 9. t_Inder which authority is application being made: -------.---- See'fown Code Chapter 237 (E)- Provide Resolution by.or authority from.the Utility being modified. 10. Estimated Cost of Proposed 1Vork: S H. Remarks:_ (�_, __�? uyh A7 C SSI j/IS l� qS_ 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 $ 1:5 V� No. 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$ 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 TOWN W SOUTHOLD,NEW YORK .. aniel . Goodwin 7- Z ? Dt 7 � Date Received by the Town Clerk 2 '�.7 2 -� Date Permit Issued �'�2-7/2,-L Ee'rmit No. ) 62- S 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# Highway Department Engineer(with page 3) Applicant Town Cleric (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1St 2nd 3 rd 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-3 9 3 of 3 IOSS I� i i e , u �® DATE(MM/DD/YYYY) A C" CERTIFICATE OF LIABILITY INSURANCE 9/26/2022 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 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 NAME: Oberle Risk Strategies, LLC PHONE 636-391-0700 nlc No):636-391-0715 8820 Ladue Road, Suite 302 c IL Ex,): St. Louis MO 63124 ADDRESS: donnas radle oberle-risk.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Starr Indemnity&Liability Co 38318 INSURED CDLUN-1 INSURER B:Navigators Specialty Ins Co 36056 CDL Underground Specialists, LLC 821 W Jericho Turnpike INSURER C:Travelers Indemnity Company 25658 Suite 6-C INSURER D:Travelers Indemnity Co Of America 25666 Smithtown NY 11787 INSURER E:TRAVELERS IND CO OF AMER 25666 INSURER F: COVERAGES CERTIFICATE NUMBER:843028238 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCEINSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY C X COMMERCIAL GENERAL LIABILITY Y C05R353463 9/25/2022 9/25/2023 EACH OCCURRENCE $2,000,000 'AMAGEO ENTED CLAIMS-MADE �OCCUR PREMISESTER occurrence $300,000 MED EXP(Any one person) $5,000 X XCU Included PERSONAL&ADV INJURY s2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 JECT POLICY❑X PRO LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: s D AUTOMOBILE LIABILITY BA5R347352 9/25/2022 9/25/2023 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIREDX NON-OWNED PROPERTY PROPP RdT nDAMAGE $ AUTOS ONLY AUTOS ONLY — A UMBRELLA LIAB X OCCUR 1000586586221 9/25/2022 9/25/2023 EACH OCCURRENCE_ $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000_,000 DED X I RETENTION$n $ E WORKERS COMPENSATION UB5R352558 9/25/2022 9/25/2023 X AND EMPLOYERS'LIABILITY SEATUTE OF:R ANYPROPRIETOR/PARTNER/EXECUTIVE YN E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? NIA (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 B Excess liability NY22EXCZ06DRMIV 912512022. 9/25/2023 Each occ/agg 2,000,000 C Equipment floater C05R353463 9/25/2022 9/25/2023 Leased equipment 250,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016,03) The ACORD name and logo are registered marks of ACORD