HomeMy WebLinkAboutOld Main Rd, Mattituck
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JUDITH T. TERRY
TOWN CLERK
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1800
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
December 10, 1997
Custom Commercial Construction Corporation
76 Brook Street
Bay Shore, New York 11706
Gentlemen:
Returned herewith is your $350.00 Maintenance Bond with regard to
your installation of underground electric services for Cofam Realty
Company, Old Main Road, Mattituck, which permit was issued on May 18,
1995.
Very truly yours,
~~
Judith T. Terry
Southold Town Clerk
Enclosu re
.n~--- ___~IUI~-_;ro; -__
/~II"'''''~~' TOWN OF SOUTHOLD . 50;,';"'__
i! ~ 53095 MAIN ROAD NO. 045424
~ SOUTHOLD. NEW YORK 11971-0959
DATE
12/09/1997
THE SUFFOLK COUNTY NItTlONAL BANK
CUTCHOGUE, NY 11935
CHECK ,'\10 AMOUNT
45424 $350 _ 00
THREE HUNDRED FIFTY AND 00/100 DOLLARS
i
~A'(TO
THE
ORDER
OF
CUSTOM COMM. CONSTRUCTION CORP
sr--\..:) Co~
11'01. 51. 21.11' 1:0 nl.o sl.bl.l:
b 3 00000 I. Oil'
,ENDOR 003778 CUSTOM COHM CONSTRUCTION CORP 12/09/1997
ACCOUNT :ilQ ~J'~Ol:=E ESCR'P' ~~ \M(l('Nr
CHEC-
45424
11 .030
120497
SURETY/MAINT BND-f--~Y Ei<C :;SO.OO
"':"i1T~1
--:~il l~i('.
TCWN OF SCt.iTHCLD . SOUTHOLD. NY 1197~ ~0959
,"._-,-
'.
.~. P.~rmit No. ./-J_
File' No. /3
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fOWN OF SOUTHOll)
IIIGIIWA Y DEPARTMENT
Peconic lane
Peconic, New York 119S8
(516) 765-3140
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APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
_..____n __0__ ___.._____ _.'"___._.__._____..__
APPLICATION IS IIEREBY made to the SUPPI-illt",,,lent of lIighways of the Town
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New Yor!<, and other applicable laws,
ordinances or regulations for the excavation herein descnbed. The applicant agl-pes
to comply with all applicable laws, ordinances, codes and regulations, and to pem,it
authorized Inspectors to make necessary inspections of the job site.
Print or Type
1) CUSTOM COMMERCIAL CONSTRUCTION CORPORATION,
Name of Applicant
76 BROOK STREET, BAY SHORE, NY
--- ---Adcfi'ess------------
11706
2) COFAM REALTY COMPANY, 4623A SUNRISE HIGHWAY, BOHEMIA, NY 11716
Name of Owner of Premises ---~.------l\ddi:E;ss-------------
3) INSTALL ELECTRIC SERVICE !,lNDERGROUND. OLD MAIJ:Vl-Q_~-; MaTITlliCK.-_ID'._______
Work Description and location (Street Numbe'-. Hamlet. Cross SIt-eet)
(a) Is construction located within 75 feet of tidal wetlands? 'Yes
*If yes, other Town permits may be required.
No X
4) Builder's License No.
Plumber's License No.
Electrician's License No.
3987-E
-----JP-
Applicant
_4.L4/95_________
Date>
5) a) Attach plot plan showing location of propos"d exc-<lvation <lnd relalion,hi!, I"
adjoining premises or public streets or al-eas, and giving a detailed descrip
tion of layout of excavation.
b) Attach all other necessary permits and licenses for Ihis project.
c) Work covered by this application may nol commence before issuance of il
Highway Excavation Permit by the Town Clerk.
6)
7)
Tax Map:
Section 100Q.___, Block
122
. lot
7 3.1
_.- _._._----~--
Starting Date: -2i01 /95
Completion flal" 5/14/95..__________
8) Work Schedule:
PI~~_e.c::om(JleU()n ~il.t.e
Excavation. .......................... ... . .. ...... . . 5/01/95
Facility Installation................................. 5/01a5._______
Backfill & Compaction.............................. 5/01/95
Pavement Replacement.............................. ___?J14/22_____
9)
Under which authority is the application mad,,:
10) Estimated Cost of Proposed Work: $..L.5..Q.Q~O_Q___________
11) Remarks: EXCAVATING TRENCH FOR UNDERGROUND ELECTRICAL SERVICE.
."'~ .-------
0-39
Page 1 of 3
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,12)
.
.Insurance Coverage: (A ttach
a) Insurance Company:
b) Policy #___
c) State whether policy
ment: NO
copy)
HOME INSURANCE: S1M9261403
COMMERCIAL UNION INSACE: CJAG490S0
FEDERAL INSURANCE: BJ'r1S3A
STATE INSURANCE FUND: 6460802
_._..~_....._-- ------._-----_._- ..~..~~,-_.._-_.__..._.- _.-
ZURICH INSURANCE: 1944217-001
of certification oil file with the Highway Depart
d) Coverage required extended to the Town:
Bodily injut-y and property dam",!e: $300,000/$500, OOf) Bodily Illjllt y.
and $50,000 property damage.
13)
Security:
a) $L;rety Bond
tota I amount
c. Certin~d Ch~c1,.L:_..__Pt'O\';d:"J il~ th~
f$ "?~ 00
o "",,50-
Maintenance Bond provided: I<I1Ct~ea"s or__.___.3 years
b)
14)
Fees for applications and permits:
A 1. IService Connections
~
Basic Application Fee........ $25. 00
- - .'.-.-- ----- -. - -- ...--.--..----------
excavations @ $20. 00 ~ $
A2.
~
B. Excava lions 18" in depth or less:
0-100 I. f. ~ $10. 00
I.f. @ $0.10 - $_____..__
IAdditional Excavations same se,'vice @ $10.00= $
Additional
C. Excavations 18" in depth to 5' in d"pt"
0-100 I.f. = $30.00
il 1'76~__
__':L~__I. f. @ $0.30 = $ v
Additional
D. Excavations 5' in depth and ovet":
0-100 I.f. = $50.00
I. f. @ $0.50 = $_______
Additional
E.
Utility Repair Excavations @$10. 00
$
No.
Repait"s same service @ $5.00. $
Additiona'-
F. Notice to public utilities proof must he 11I'ovided and attached to
this application prior to issuance of pe"mit.
. . .
Authorization is hereby ~lranted to the
issue a Highway Excavation Permit to:
in accordance with this application.
Town Clel'l, of the Town of Southold to
SUPERINTFNi>ENT OF HIGHWAYS
TOWN OUTI/OLD, NEW YORK
R;iYlllllll~ -.-----
d~_ . j~.:___2.s_
Oat"
Received by the
Town Clerk. ~/;f!~-
--:1!- -------..-- ._-
ate
~f;%/~s
Da tEil,L_C
...~..
Permit No.
--p-------
Permit Issued
Note:
Permit expires one (1) year from Date of 'ss!lance.
No work to start without 48 hour notice tC' Ihe Supe,-intendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
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Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
.
.
INSPECTOR'S
RECORD
Inspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
D-39
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 to repair
.<\...........
Page 3 of 3
BIRCH BRPOK AGENCY INC
P.O.BOX 2';>8
COMPANIES AFFORDING COVERAGES
CROTON FALLS,N.Y.
(914)::!79-.6C,OO
NAME AND ADDRESS Of INSURED CUST :~: :!. (0)'2
1051 ';'
COMPANY A
LETTER HOME I NSURf'\NCE CD"
COMPANY B
LETTER COMMERC I (:iL. UN I ON INS
COMPANY C
LETTER FEDEPAI... I NSUF!ANCE CO
CUSTOM COMMEPCIAL CONSTR
CORP., 76 BROOK STREET
P.O. BOX 711M
BAYSHORE, NEW YORK 11706
COMPANY D
LETTER STATE: Hm. FUND
COMPANY E
LETTER zur~ I CH I NS ~ CO..
Tn's is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. Notwithstandjn~ 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 escribed herein Is subject to all the
terms, exclusions and conditions of such policies.
POLICY Lim ts 0 L abll n ausan s
TYPE OF INSURANCE POUCY NUMBER EXPIRATION DATE EACH AGGREGATE
OCCURRENCE
GENERAL LIABILITY BODILY INJURY , ,
t-l IZl COMPREHENSIVE FORM m_(W~,61403 07 /O4/9~:;
o PREMISES-oPERATIONS PROPERTY DAMAGE , ,
00 EXPLOSION AND COLLAPSE
HAZARD
[Kl UNDERGROUND HAZARD
o PRODUCTSICOMPlETED
OPERATIONS HAZARD BODlL Y INJURY AND ,1000 ,2000
~ CONTRACTUAL INSURANCE PROPERTY DAMAGE
o BROAD FORM PROPERTY COMBINED
DAMAGE
[3] INDEPENDENT CONTRACTORS
[Z] PERSONAL INJURY PERSONAL INJURY ,1000
AUTOMOBILE LIABILITY BOOIL Y INJURY ,
B o COMPREHENSIVE FORM C.J~,G490~iO 0,;/04/'1,:; (EACH PERSON)
BODilY INJURV ,
[Z] OWNED (EACH ACCIDENT)
IKI HIRED PROPERTY DAMAGE ,
[] NON-QWNED BODILY INJURY AND 1000
PROPERTY DAMAGE ,
COMBINED
EXCESS LIABILITY
C [Z] UMBRELLA FORM K\3153A 07/04/'1,5 BODlL Y INJURY AND , C;OOO
PROPERTY DAMAGE
D OTHER THAN UMBRELLA COMBINED
FORM
WORKERS' COMPENSATION
D and 6460802 0712M95
EMPLOYERS' LIABILITY
OTHER
E DISABILITY 1944217.-001 07/04/95 STAT.
DESCRIPTION OF OPERAnONSIlOCAnONSNEHlCLES
- PEl ALL OPEPATIONS, ALL LOCATIONS -
INSURED: TOWN OF SOUTHOLb, HIGHWAY DEPT.
MAY 1 8 1995
Southold T nW" C1-"
Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail 30 days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company.
NAME AND ADDRESS OF CERTIFICATE HOLDER
TOWN OF SOUTH OLD
HIGHWfW DEPT.
PFCDNIC LANE
,PECONIC, N"Y.
DATE ISSUE<> 04/03/'15
L
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11 ';'58
/<<-
U. .:NT ' I ~
AUTHORIZED REPRESENT~n~E/
"ThiS '$ an older ~er$lon ot the ACORD 25 torm and IS being phased out Th,s torm
may not conta,n all 01 the ,n/ormat.on currenlly reqUired by your Insurance
company or bylaw"
IiON
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Highway Department
Town of Southold
Peconic Lane
Peconic, N.Y. 11958
RAYMOND L. JACOBS
Superintendent
Tel. 765-3140
.734-5211
DATE:
TO:
CASE NUMBER:
This is to notify you that New York Telephone Company
and Long Island Lighting Company have been notified in
respect to the application for an Excavation Permit in
the Town of Southold.
e applicant
Sign
UTI u.I'1 D\b. C~C AID. 1//cUJ3fo
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