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HomeMy WebLinkAbout200 Mathews Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 03/06/24 Receipt#: 323783 Quantity Transactions Reference Subtotal 1 Excavation Permits 1710 $500.00 Total Paid: $500.00 Notes: Payment Type Amount Paid By CK#9000267143 $500.00 PSEG, LI Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: PSEG, LI 448 E Main St Patchogue, NY 11772 Clerk ID: JENNIFER Internal ID: 1710 Permit No. ( V � ,L g TOWN OF SOUTHOLD HIGHWAY DEPARTMENT - �, Peconic Lane Peconic,New York 11958 0� (631)765-31401 APPLICATION/PERMIT FOR RrGHWAY.EXCAVATION ANDREPAIR 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,ordiinamwes 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 peruut authorized inspectors to make necessary inspections of the job site. Printor Twe 1. �� ��� �; �+�► � P cam, �� J�� �-- Name of A licant Phone Number Address Applicant 2. Name of Contractor Phone Number Address of Contractor 3. 7 ; Y Z,- Name of Property Owner Requesting Service(if applicable) Address of Owner 4. F5E&L-1 &LWtkM`� Ser�LC��-x.19- A-� D >�ttP IA-0 JA--/l e- CL n Flke 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. 5c. NOTE: All information requested by this Signature bf Applicant Application/Permit Form isI j�� � 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 Block , Lot 7. Starting Date: _ 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 5 12. Insurance Coverage:(Attach Copy) rr --.-(a)__Insurance Company; M ,�/ ( #?-P (b) Policy#: WA —5 - 0 Z)'' / �y ?3J1 A 0 —1,01:2-- (c) ,01:2-- (c)State whether policy of certification on file with the Highway Department: L�y (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 - r $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 approvalof the-Highway Superintendent: A 1. /Service Connections excavations @$50.00 $ No. A2. /Additional Excavations same service @$20.00 $ No. B. Excavations 18"in depth or less 0-100 L.F.=$1,000.00;Additional L.F.@$10.00 $ C. Excavations 18"in depth to 5'in depth 0-100 L.F.=$3,000.00;Additional L.F.@$30.00 $ D. Excavations 5'in depth and over 0-100 L.F.=$5,000.00;Additional L.F.@$50.00 $ E. Utility Repair Excavations @$1,000.00 $ No. Repairs same service @$500.00 $ Additional TOTAL$ F. 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. SUPERIN ENT OF HIGHWAYS WN TOS UTHOLD,NEW YO, oc Date Received by the Town Clerk 12o Z-y Date Permit issued 31(112102—q Permit No. I q- I O 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 5 -------- --- ------------- - - -- ----- --- Copy Distribution:- -- I - - --_- Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS -----Inspection-Da+e — - Findings=Oise cede)- - Applicant Notified i st 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 WIP Work In Progress DB Improper Backfill(too high,not sufficient) HITS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 5 H SIDE(9) STREET(10.20 ` NRELEASE UMBER 010 515 Cid0lvw �-.-1�• i FT FROM(32-35) sa%(38) CROSS STREET(3747) MAP(48.53) AREAWORK ORD R fi Go N PRI SEC 0 (54.65) �' PAVMG EXCAVATED STRATA TYPE PAVING THICKNESS SIZE CODE PAVING M9PECTION NOTES'- -7 (� I I I DATE INSTALLATION PAVING PERMIT NO. OR REPAIRS COMPLETED ^f Z JOB STATE FOREMAN'S c' COST NO. SIGNATURE COUNTY INSTALLATION JOB COST NO. TOWN TEMPORARY PAVED ES O NO VILLAGE WORK START / / WORK COMP. / / CITY &XIETCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . : . . . . . . . . . : . . . . . . : r,,�r;,f6-J .09 . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WARM Elecnor••Hawkove -.� CLAW CAT. ,u, 0AUX GOLD-INSTALLATION COPY GREEN-U,RD.OFFICE COPY PAVING CARD MANILLA TAG-KEYSPAN COPY INDICATE PATCH SIZE A ITEM STRATA ftTWTED ACTUAL DISTANCE FROM CURB. 211 212 214 CURBLIINE OR EDGE OF ROAD EMERGENCY REQUEST FROM CONSTRUCTION Request for: TOWN OF SOUTHOLD DATE: 2/21/24 PERMIT REQUIRED TO OPEN: PSEG DRILLED IN NEW SERVICE TO HOUSE 200 MATTHEWS LN IN CUTCHOGUE. THE ROAD OPENING IS APPROX 333FT EAST OF COX LN. PLEASE RETURN PERMIT TO DAN PAPPAS FIELD SUPERVISOR: Number of Road Openings: 1) In Grass Areas 2) In Roadway Areas 1 Approximate Start Date:January 24' Approximate Completion Date: January 24' DIVISION: EASTERN SUFF NOTIFICATION # TD: TYPE OF ROAD MACADAM WORK ORDER# 800000408570 RETURN PERMITTO: NEW BUSINESS DEPT CONSTRUCTION DEPT. X DATE(MM/DD/YYYY) ACC)IR�® CERTIFICATE OF LIABILITY INSURANCE 05/1612023 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 MARSH USA,LLC. NAME: 1166 Avenue of the Americas A/C NNo Ext), FAX No): New York,NY 10036 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN 1 19109855-AUWC-23-24 INSURER A:Associated Electric&Gas Insurance Services Limited 3190004 INSURED INSURER B:LM Insurance Corporation 33600 LONG ISLAND ELECTRIC UTILITY SERVCO LLC 333 EARLE OVINGTON BLVD INSURER C:NIA N/A UNIONDALE,NY 11553 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-011006564-09 REVISION NUMBER: 3 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR S POLICY NUMBER MM/DDIYYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 7 OCCUR DAMAGE S(RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F—]PROJECT ❑LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED FIR PER DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR XL5368110P 05/15/2023 05/15/2024 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB HxCLAIMS-MADE AGGREGATE $ 10,000,000 DED I X I RETENTION s3,000,000 $ B WORKERS COMPENSATION WA5-69D-463428-012 =12022 12116/2023X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OF N N/A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION New York State Department of SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Transportation Permit Section,Region 10 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Perry B.Duryea,Jr.State Office Building ACCORDANCE WITH THE POLICY PROVISIONS. 250 Veterans Memorial Highway Hauppauge,NY 11788 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN119109855 LOC#: New York ACC)IOR o ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA,LLC. LONG ISLAND ELECTRIC UTILITY SERVCO LLC 333 EARLE OVINGTON BLVD POLICY NUMBER UNIONDALE,NY 11553 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Excess Liability includes the following retentions:General Liability,Automobile Liability and Pollution Liability$3,000,000;Employers Liability:$1,000,000. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE 71807826 1 9-463428 1 12/22-12/23 C105.2 (51-11565) 1 Erin Celing 1 12/19/2022 10:27:04 AM (CST) I Page 2 of 2 YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Long Island Electric Utility Servco LLC (800)490-0025 333-Earle Ovington Boulevard Uniondale NY 11553 1c.NYS Unemployment Insurance Employer Registration Number of Insured 51-11565 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 45-4652143 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) LM Insurance Corporation New York State Department of Transportation 3b.Policy Number of Entity Listed in Box"1 a" Traffic and Engineering 250 Veterans Memorial Highway, Rm.6A-7 WA5-69D-463428-012 Hauppauge NY 11788 3c.Policy effective period 12/16/2022 to 12/16/2023 3d.The Proprietor,Partners or Executive Officers are Q included.(Only check box if all partners/officers included) E] all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. 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 the coverage as depicted on this form. Approved by: Diane Beaudoin (Pd-- ----------•-`insurance carrier) Approved by: � -� � 147,) 12/19/2022 (Signature) (Date) Title: Sr.Customer Service Coordinator Telephone Number of authorized representative or licensed agent of insurance carrier: 401-248-9924 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov 71807826 19-46342B 1 12/22-12/23 C105.2 (51-11565) 1 Erin Celing 1 12/19/2022 10:27:04 AM (CST) I Page 1 of 2