HomeMy WebLinkAbout360 South Harbor Rd Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 04/27/23 Receipt#: 309772
Quantity Transactions Reference Subtotal
1 Excavation Permits 1662 $550.00
Total Paid: $550.00
Notes:
Payment Type Amount Paid By
CK#6899 $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: JENNIFER Internal ID: 1662
Permit No.
TOWN OF SOUTHOLD
RECEIVED HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958
APR 2 6 2023 (631)765-3140
Southold Town CleriAPPLICATION/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 Type
1. ms's l )N�QVCAI--00Y-0 041 (4i(!� 3 f C��o b/aha ATG hc�• ccs
Name of Applicant k.JPhone Number Address of Applicant
2. -k�p_ 2db -, C-) Dr p 9�
Name of Contractor Phone Number Address of Contractor n �� o
3. �� 5• � �,�i/ a� Y-5
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. ctOd vr!def d nU /holea OCrr 55 g ) reenj
Work Description and Location(Street Number,Hamlet,Cross Street ele,�4rroj,( 7qDp,,-- GG
(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 gignature of Applicant
Application/Permit Form is
Required for a complete application!
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 Jr , Block g , Lot 3.
7. Starting Date: aerle((t, 4Qr04 4101, y/��3 � Completion Date:
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:
D-39 1 of 3
12. Insurance Coverage: (Attach Copy) /
(a) Insurance Company: ,,/yC u I- — 10 CL (i i5iu-se
(b) Policy#: LJ
(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 dotal number of Project Locations shall be subject to the approval of the Highway Superintendent.
Al. ( /Service Connections excavations @$50.00 $ 5-01. Cfd
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 SO THOLD NEW YORK
Gra. L� �V
y
<XZ
L
Date Received by the Town Clerk 4f 2'6 1 2S
Date
Date Permit Issued 412r[123 Permit No. u j 2—
NOTE:
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 Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
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 3
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AC40R"' CERTIFICATE. OFUABILITY INSURANCE
05/02/2022
THIS'CERTIFICATE!IS.ISSUED
UED AS A MATTER
TTER OF,INFORMATION'ONLY AND CONFERS NO RIGHTS UPON-tHEd-ERTIFICATE HOLDER.31-II&
CERTIFICATE DOES NOT-AFFIRMATIVELY bFt''NEG-ATIVELY AMEND',EXTEN-D!OR ALTERTHE COVERAGE AFFORDED 13Y THE POLICIES
BELOW. THIS CERTIFICATE:OE INsultANCE,DOEs NOT CONSTITUTEA CO EEN-TktL'ISSUING'INSURER(S),.AUTHORiZED
CONTRACT BETW
REPRESENTATIVE OR PRODUCER,AND,THE CERTIFIGATEHOLDER.
�IMPORTANT: If the certificate,,hOlder is-an ADDITIONAL.INSURED,thepolicy((es)must-have ADDITIONAL:INSURED!p!,ovirionsor-ii6lefidorsed'.
IVED,subjelctlo the�terms and conditidns of the ip
if,sU9ko.GATibNi_18"WA olicy,certain:policiesmayrequirean endorsement. A statement'on,
'this ce'rtifidatLidoes:not,,conterr'ig6tsiothe certificate hplder�itilieu!bf'SUGhendorsement(s)-.,
PRODUCER CONTACT
PROD
NAME, William,(Waij Fontaine
Bay�Harbour'iiis,A�gen�cy,,Inc!. -
PHONEIX
f� 0 FAX �-2176
JCi Ext3: (631)758-1550 (A No)- (631)289 -
89 Waverly Avenue E-MAILssr serVi&d§bayharboijrgtOup.COM
ADORE
;Patchogue, NY 11772 INSURER(S)AFFORDING:CDV-ERASE NA.ICV'
INSURER A: Evanston lnsuranq6.Company
INSURED, INSURERS: Zentury.Surety'Cornpany
:Joe's Underground Utilitids,16c, WtORER
&Gull Dip!Road INSURER D':
Rl1dgp,,W"I 1961 INSURERIE,
INSURER,F
-
'COVERAGES' CERTIFICATE NUMBER. 000112571A067719 REVISIOWRIJIVIBER. 1'-
THIS-18 TO CERTIFY THAT THE,POLICIES:OF11NSURANCE LISTED-BELOW,HAVE BEEN.ISSUED TO THE INSURED NAMEO:ABdVE FOR THE POLICY PERIOD
— I Tfo . .. . ..
INDICATED; N6-rWITI(STANmN(;,ANY REOUIREMENT,TERMOR CONDITION;OF ANY CONTRACT OR OTHER'DOCUMENT WITH RESPECT - WHICRTHIS
CERTIFICATE MAY,BE ISSUED-OR MAY PE�,ZT,41N,_THE INSURANCE-AFFORDED-BY THE"POLICIE'S DESCRIBED HEREXIS SUBJECT TO ALL.THETERMS,
EXCLUSIONS AND'CONDITIONS'OF-SUCH-POLICI'ES�,,LIMITS;sHbvVN 0AYHM BEEN REDUCEDBY PAID CLAIMS.
!NSR AODLISUBR POLICY EFF POLICY EXP
LTR TYPE OF NSURANCii IN'sD WVD POLICYNUMBER s(MMIDDIYYYYYL '(MM1DD1YYYYj.' LIMITS';
A A COMMERCIAL GENERAL LIABILITY '3FF1 322 0411912022 041.294023 'EACH OCCURRENCE 0..,0_00
�DAMAGETOI-NTED
do
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CLAIM&MADE' NxIOCCUR :PREMISES(E.'occurrence $
MED,EXPjAnyZne person)1 $ 5,000
PERSONAL'&ADV1NJUIRY $ 2,000',000
GENIL AGGREGATE LMFr APP-LIES- PER: GENERAL AGGREGATE 4,000,00,0,.
01PR?j _jLOC PRODUCTS-COMP/OP AGGI 4,000',0W
POLICY PEC F $
OTHER: -COMBINED SINGLE LIMIT $
AUTOMOBILE LIABILITY
ANY AUTO BODILY 0 ILY INJURY,(Per peirson); _$
OWNED SCHEDULED -BODILY INJURY,(Per,accident)
AUTOS ONLY AUTOS
1HIRED NON-OWNED PROPERTY
DAMAGE
Per
AUTOS ONLY AUTOS ONLY accident I
$
:B IAB X, OCCUR CGPI 062069, 04129/2022 0412911.023 1 EACH OCCURRENCE I'Mo'gou
:EXCESS LIAB fGLAIMS-MADE AGGREGATE
CfEb RETENTION$
WORKERSZOMPENSATION RT ETH
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AND<EMOYERS'.LIABILFY STA UTE ---FOER
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ANY PR PRIETOR/PARTNERIEXECUTIVE' E.L,EACH ACCIDENT
ERJME BEREXCLUDED' 'NIA,
bFFIC'O F
(Mandatory IM.21, E.L;DISEAGE-EA EMPLOYEE
Ifes vd scribe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-P.OLICYLIMIT 4,
DESCRIPTION:OF-OPERATIONS I LOCAT'ONS)L VEHICLES 4(ACORD 161,Additional Remarks,Schedule;maybe attached If more spaceds requked)-
Install/replapeCATTV-Lin'ps and or conduit:
CERTIFICATE HOLDER'. CANCELLATION
SHOULD ANY OF THE AI36VE'DEE8CMBtD PpLICIES.'BEI CANCEULED'BEFORE
E
'THE EXPIRATION DATE T'HEREOF,',NQTIQE WILL'9E'DkLIV91RED*
-Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS.
$3095'.Rte,25 Po'Bbx 11791
SoUtholdNY 1-101
AUTHORIZED REPRESENTATIVE
Riffmei6a, (WF1)
0 1988-'2015 ACbRrYC.ORP0FrAT16N.. A11'r.1 1 ghtv res.6eved,
ACbRD V5 12016/03) Thn;Af'nPn names and Gva,gra .Ai_—i,A r-n6n, n.:�t_d L..iairoi __ArJA6).Aha,—
Aug, 1 U, 241:1 j', PUTM 4N0, 7,.,1,4 r, j,I:
MYS- ;F
New:voAtstatonsurejfc6 F.uhd `PO Box-66699,A.lbany�!NY 42206
nyslf.com
;CERTIFICATE OF WORKERS"C17111`ipENSATION INSURANCE
,AAAA.&*' 33121267.7
SPEGIALIZED'I NRURANCE.&
SERVICES INC
•204 ROUTE 112;
RATCHOCiUE,NY 41.772 SGAN,To VALLDATE;
AND 8UBSCRIBE
POLICYHOLDER CERTIFICATE?HOLDER
JOE$:UNDERGR'OVND UTlGITIEq'INC: V TOWN.OF SOUTH OLD
8 GULL DIP ROAD 53095 ROUTE 26
RIaGE NY,11961 PO,BOX 117J'
soUTHOLa NY 11956'
POLICY NUMBER CERTIFICATE_14 ER. PdLIG.Y pf=RIOD DATE;
12157 303 . 14-1275, 06h 0!2022 TO :09!1012023 8L10l2022
THIS: IS: TO 'CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED;, WITH THE' NEN YORK BTATEINSURANCEi
FUND UNDER POLICY .NO:, ,2157 30&2;, OOYERINP THE ;ENTIRE QBLIGATION OF ,THIS FOLICYHOLDER', FOR.
WORKERS' COMFENSATION 'UNDER, :THE, NEW YORK; 'WORK@RS',COMPENSATION LAW ;WITH ;RESPECT TO, ,ALL
OPERATIONS IN 'TME STATE QF' NHW YbkK, F-XQE PT AS', !NOir.ATED SELO_W;, :AND, WITH RESPECfi TO OPERATIONS;
OUTSIDE:,QF ,NEW YORK, TO: 1-IS,POLI.OYHO.4D.ER'3 REGULAR NEW YQRK STATE EMOLOYMS ONLY, -
IFYOU WI.SH,TQ,RECEIVE'.NOTIFIGATIONS REGARDINO,SAID:POLICY;INCLUDINClANY NOTIRICATION:OF CANOP.LLATIONS',
OR TO�VAL(DATE THM!GERTIFICATE,,VISIT OWR WEBSITE AT'MtTPB,IIWWW.NYSIF.COMICERTICERTVA"SP�TWE AW
YORK:STA,rklNSURANCE FUND IS NOT,LIABLE;'IN,THE'EVENT�OF':FAILURE'TO,QIVE-.rUCH NOTIFICA, 6NS.
THIS POLICY DOES.NOT COVER`CLAIM5 OR SUITS,THAT ARISE FROM`BODILY INJURY SUFFERED,BY THE OFFICERS OF78E.
INSURED-CORPORATION.
:JOSEPKROSSON(PRES)OF
J0E8,UNDERGR0UND-UTILIT(E8 INC
(ONES PEM0N CORP)
THIS CERTIFICATE 1S ,ISSUED AS.A 'MATTER,-OF' 'INFORMATION ONLY:ANQ'.CONF.ERS .NO RIGHTS NOR.INSURANCE:
COVERAGE UPON THE -CERTIFICATE; -1HOLpEk `THIS. CERTIFICATE DOES NOT .AMEND, 1=XTE41) OR. ALTER
THE COVERAGE:AFFORDED ,BY'1'HE;POLICY;
NEW YtJ'FtK:STAT N$U NCE FUN17,
WRECTONINSURANCE;FUNO UNDERWRITING
VALloATiON.NUMBER:4054fi359
uze,a
YORK VNorkers' CERTIFICATE OF INSURANCE COVERAGE
sTATk Compensation
Board ,NYS DISABILITY AND PAID FAMILY LEAVE,BENEFITS LAW
'PART I.To be;completed by,NYS.disabilityand'Paid Family. Leave benefits;carrier or licensed insurance.agent'of that carrier
1a,.1 al,Name&,Address,of insured(use-street,address only) 1b:Buslness Teiephone-Numtier:of'Insured
JOE'S UNQERGROUNf QTILITIES 1NE 631-484-85'12
'B GULL,DFROAD
RIDGE,NV 11061
1c.Federal,Employer•identlfioatlo_nNumbar.of;Insured:
or Sodlal•Securityadutnbe�
Work;Locatlon of•I n.sur2d(Only required if coverage is speciridally limited to
!certain.localions.fi New York State,l.e.,)Y-P-up P-11-Y), 3312126.77
:2.Name and Address of Entily.Requesting P.roof.of,Coverage, 3a;Name of'.InsuranW Carrier
(Ertitily 8eing Llsted.as the Gertific3ie Holtler): Shel1teiP.oin1t1ffeansurance Company
'TOWN OF SOUTHOLD
53Q95 ROUTE 25. .'3b.Policy Number'of Entity Listed in Sox."1a"
MOM 1179, DBL2606,77
SOUTHOLD;NY 1195:8 3c.Pbllcy effective period.
09122/202-1 to 00/, 1- 2023
4. Policy provides the following benefits:
A.Both disability and pafd:farnily leave benefits,
B.Disability.bane_fits only,
C,paid family leave benefits only,
5. Policy covers:
A.All of the employer's empioyees,eligible:.underthe NYS'Disability,-and Paid Family'Leay.aZenefits Law:
0 B.°Only the following class o(diase-es of empfoyeeg employees:,
Underpenally:of perjury,:I certify that.I am an authorized representative or licensed agent of the Insurance carrler re erenced'_abcve and that,the named
Insured;has NYS'Disablllty and/or'Pald Family Leave Benefiis,insurancecoverage as described above.
Date:Sidned 3728/2022 By h19!
(Signatufe of j6surancexartiee..s authorized representative or NYS Licensed,Insurance,Agept;of.thatinsuranie carrler)
Telephona Number 51'6-829-8100; Name and Title Richard;White, Chief"ExeCutive•Officer
IMPORTANT- If:Boxes.4.660'5A'are ch6cked';and,this form is.;signedby.the'insurance•car�ier's-authorized representative or NYS
Licensed'.Insurance Agent.of that carrier;.this.certf1ficate:is.t:OMPLETE:.Mail;it directly,to'the,certificate h-older.
If Box 4B,4C or.513js.checked,this:certificate;Is NOTCOMPLETE for purposes.of Section 2204Subd..B.of the NYS I
Disability and Paid Family.Leave Benefits:Law, It trust be-amatled to!PAUri_wcb:ny;gov'or it�can be:,malled;for• j
completion to.the Workers'Compensatlon Board;Plans Acceptance Unit, PO.Sox:5200, Binghamton,NY 13902-5200. !
PART 2.To be completed by the NYS Workers':Com ensation Board(Only If0ax.413,4ror5B tiave:been;checked): I
State,of New'York.
Workers' Compensation Board
Accordfng to information maintained Dythe?NYS:Workers'Compensatlon Board,.t0e above;named employer has,complied with the,,
NYS,Disabllity,and,!Pald Famfly Leave'Benefits Law(Article;9,,of theWorkers''Compensation:Law)witty respect to all:of,lheiremployees.,'
DateSlgned , By
(Signature of Auihorfzed NYS warkers''•Campensatian eoard'E•mployee)
Tele0hone Number Narne and Title -
Please Note:Only Insurance.carriers licensed to write-MS disa_bjIlly and paid family leave benefiis;lnsuranoe policies and N,Y,S hceirseaf Insurance.
agents of1hose insurance carriers,are:authodzed do Issue;Form DE 20.1.insurance brokers are f OT authorized to'issue this'lorm.
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