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HomeMy WebLinkAbout2120 Crown Land Ln . I "'; II:.! II~ 1 1I~1 n 1 \.\ .", [I> 71i.j 13115 . . 'j1Il"I"HlJLlI (l.ERK I"Jllll1 Pt'lll1it Nu. -d. ~.5.. rol. Nu. d<6.S_. TOWN or SOUTHOLD HIGIIWAY DEPAHTMENT Pecollk Lane Peconic. NC'!w York 11958 lc.'f11!) 765'3100 ,~i Al'rLICATION!!'.J:.~MIT .F()Il~I!!C;!I.Wp'Y EXC~Y_~:r~ON AN.D R~PAIR. APPLlCA1ION IS HEREOY ml.lCJp. to th~ Supcdntend~nl of Highways of the Town "I' SlIulhulu 10. thl~ i<;Sll.uKe of em Excavation Pet"mit pUl'suanl to Chapter OJ of 11le' C.)d~ uf tht! TOWIl 01 Southolrl, 5uffoll\ County. New York, and other" applic41.)Ie laws, tlldlll<lnc:e~ or I eyuldtiolls for the excavation hnreln described. Thp. lIppHCanl a~lrl::!e~ lu comply with all applkable laws, ol"dinances, codes and regulations. ;'Iud to permit ,1ulhudz.;od im.pp.cltws to make l1eCCS,UI-Y In<;pections uf the job site. UUllt... Pia Corp. 99 Martner Dr. Southampton. NY 11. Nriiil~()-(-^i)6ill:aill .--- .. - -'--_.-'--~Addre.ss-----~~------ P. illt OI"__T),RE:. 11 :!) N.11t1l~ of UWllci OfPtClnlses .. -------~"- .~. .-- Addr@ss --~---_. ]1.a'~O C_~PWNL~N[> lrfv..c_...-, H_ \Vod< Dw.c.dptloll and LOLHtion (Stl pet Numhel". Hamlet, Cross Street) \ (<.II Is con';ll"u<.:tion loc;~ted within 75 letH of tidal w@llarlds? "'Yes ~If Yl'S, otlH~r Town pel-milS may ue ,'equircd. _No$__ II) lJullch!ll<; L.iLPnsn No. Plumucr's License No. Flt.'{.lrician'~ ULCIISfl Nn. Olhe.' Trad..'s License No. cJL ~-H.E:qbt-~- .--- Signallll"(~ 0' Applic t ....<");- 'Z.L 0 ~,,_uf5;'t.f-- - 'i) ;~I ^ltach plot J.'lan showing location of propoied E".xc.ovation .and ,'eI2lthJl1ship La ..djoininq premises 01" public streets or areas, 8t'ld giving 8 detailed dP'SCI-ip- lion of layout of eXcllvalion. Il) Attach illl othHr 1H~c.:essary pel"mils and licensp.s ror this prolect. c:) Work cove."eu by this applicatiol1 may not commence before issllance c.f ?J Iligh\Va~' EXt:avallol1 Permit by the TaWil Clerk. 61 Ti,lx Moip: SE:!Clilll1_~_"__._"__, OIock_~__, Lot_~______ 7) Sl'W""'1 lJ'le:~ T' 2.->_._Completiol1 Dato_.9Jc.. / ~-3.-- ::) \\'cwk SCh(ldule: 1~!~I_~e I-xcavalioll.."......... " f..o_I1JP~~~O'~<l~~ ql racility Installrilioll................................. n..H.:krill c. Cornp;lctJon...... ........ ... ......... ... .________ PiJvemnnt Replacemellt.............................. Unde, which authority;, .ho applicallon ,"ade:.J~!a..B~;--h~-~~7, {! 4(5l..etlt5Io{J./ .., 0<7 l~lilll;,ted Cost or rropo~t!d Wo..-k: $ "QOO. '(,''''a'ks"7~~~~,-:!:!A~ ~ C~. ~~; t <-/ li:1$_~ ~ 0-'! t11.5~'-'c r::__~tt.q_"1oj;.-z.os,~/ V 1::>..::~jz.I?"/) CUT> WLL.l (!r)v!&~r (7? """!':'?':> ~s..! f!,?5. _"7SLL'LL.-f-"" f2 ~J<I.c7/""b th!'-:tTie::) 101 11) O. )9 Page 1 of 3 . II; uti n~ FRl UIl: -1.5 n.\ SIt} 765 1IL-t5 SUlTHOUl ClERK I1JUlJ:! " 12) .lnsuralll':~!"!,.9..~: (Attach copy) / aJ Insur.nce comp"ny:~ro<./.fJ(,cr~ Hli2..-z.c"'It~~ ~vs{l~ bJ Policy .g.t2E__Cf..I..3";J.,q~ . c) State whethet- policy of certification on file with the Highway Depal-t- lIIelll: d) Coverage ,oeqltked cxtcndecJ to the Town: Oodily Injllt'Y and p."operty damage: $300.000/$500.000 Bodily Injury, ilnd $50,000 property damage. 1 _~) Scc..:UX!~.'t..: a) Surety Bond _____0_ total amollnt of $ b) ~laintenance Bond pl'Ovlded: __2 years or .3 years 1/1) ~es for appll_catl~!!._ and permits: Basic Application Fee....... ~ A 1. _:t...:.)Scr'vlce Connections excavations iI $20.00 = $ -4o~(/ . No. or Cct'lified Check proviueU In the ^2. N'o;_./Addilional Excavations same service" $10.UO = $~____~ Excavations 18'. ill depth or less: 0-100 I.r. = $10.00 I.r. @ $0.10 - $ AJtiiiional--- ---~--- C. lxcavations 1 all in depth to S' In depth: o 100 I.f. c $30.00 I.f. . $0.30 = $ -AiJdj-f1o.'-lal-- B. D. Exc~vati(lns 5' in delJth and over: 0-100 I.r. = $50.00 I.r. @ $0.50 ' $ II.ddHloi1a1- ---"No. Utility Repalt. Excavations 0$10.00 $ I,. Repairs same service ~ $5.00 = $ .-Addi"iiOi""ial r. NoUt;e to public utilities proof must be provided and attached t., this application pl"lor to issuance of permit. . . . Authorization Is hereby gl-anutd to the "fown Clerk of the Town o( SoulhoJJ tu ISiue a Hlghw.i:lY Excavation Permll to: in al:t:llI"lJurH;c with this application. --- Iff /9:03 r Date Rl:!'~iv(!(1 hy the Town Clerk H_lQl,,^ (Q~ ~le Permit 1""Ued_--1.D_Wo-Y.;\a::,-__ Parmlt No. ~%5 "'!ole: Pel'mlt ,..xplrcs one (1) yellr from Date of Issushce. No wo,-k to sturt wllhout 118 hour notice tu the Superintendent of H .ghwftys. Perlllit must be available for inspection. D- 39 Page 2 of 3 (17 lllj II:: nn 11\1: -113 F.B: 51ti iU5 Ul-l~ SOllTHOLO cLERK flIUIJ-l Highway Department Town 01 SOUlhold Peconic Lane Peco",c. N.Y. 11958 TI-I. 76~-3140 734 S21 1 .... DATE: TO: CASE NUMIlER: 'J... qt 00 s "3> I his is tn notify you thal Rell Atlantic and UPA have been notified In respect to the application for an [xcavation Permit itl the Town of Suuthold. t~_~L Signature of the apPlicanT .- 11 2~~( (:AfoLe '# Pi;/) ItGO C4\€,le Pe D O.~ \ \ DfL\VC...v4.J I ) 1-:1: 'V' IV 0 'I ~ Ir'j Q ~ ~ \ j- ( ,Ii -:h ( r <: \) t~ ('~12.0 I """'C) \ r G ( t 1 'tUJi::lY"'1-r o----~- \fl <0 ~l I I CAt?Le Pe.o ~ ---0 M,S,(,Lt? ::tU<;'14L~ rz0"10 Q~S.ub 2" f'VC ~O"--'OU\ f U..ll/l6L" ~IlX NO. 6316815456 CERTIFICATE OF LIABILITY INSURANCE OCnl 10 2~ oO}/03 TIll! CERTIFICATE 1918SUED A8 A MATTER OF INFORMATION ONLY AND CONFERS NO mOIlTS UpoN THE CERTIFiCATE HOLDER, THI9 ceRTIFICA T@ DOES NOT AMEND, EXTEND Oil ALTER THE COVEMO@AFFORVW BY TilE POUCIE9 BELOW, ;-'Ac1)RfJ, IIULItV! "NiiJ(;lJ,:r:n JIlJt\f\n F. Sulton Auefwy 149 E. Main Street P,O. nox '16 E~.t lolJp Ny 11130 PhonorC,31-581-7970 ~unf:u- Ltd. J.&J~t~ F. SunON AGENcy COMfl.E~C~'II. LINES NEWrl\)(, (631) MI.G45d PIlONE (631) 581'/PI8 Fax'631-591-7507 IN9URERS AFFORDING COVEnAOE ---- rN'J~' N.toh&nt.l!....~.2._Co.-.of.1!~w H ~U~.~~.chaDt.~tual-.!~Cu!_ ---- --.-.-----.-----. Ulilltien Plu~ Corp 99 Mr,dner Vdvo SoutJampton NY 11968 A Nr'f/loUTO All. OWNtO AtJ'O~ tCHEDUtEO Amos 111!lFDAUT09 NO'I 01......1:0 ^UfOS '-'- --- ~'- -- CAnAnc U,A"IUf., "NV^UlIJ B CXCt!l~ft,.tllA WUrlU1Y .=J OCCuH 0 ClAIfA! M^DE CUU065762 Otoucrl1JI.E X "CTEN11O" 110000 WOnK!A~ eourlf{9ATIOH Af<<J r:MrLonns' UAIIIUN A"IY l'AOl'nltl\.~A".ARTNE~rcUnvl! O'F'ICEMlt::VOC;A rxcI.UU!P1 :~fel~~~~nt'v~!.~r,s 1:1;,1""" OrtU:'11 INSvnERO: tNoUn," 0: lNSURtR 5; NAIO. '--'--- 03__.__ ~-- ---..-- .._~_.-._,.- --------~- -----, OS/23103 FAtH OCt;UHRtNCF_ D1IWG1! 111"""",-- .rmr~~oc~..!l_ M~)(!J:~!!~'llon) PF.nSONAl. . AD\! tlJUAY '-'-----. ~~~'!~.- PRODUCTS. COMP.op Mil) __0_. COVEOAOES ~ - II'F-" ro\"'(lfs OF-" l"lsunNICE liStED IIF.I ow UAl/Ti ftHtll!l!';UED 10 'HE INSl,:nEO kAl.4CU /I8OVC FOf1 TJlUPOUCY rERIOOINOICAno. NoTWnHST"""OIHG ""'v P~OUIRt'JFNT, ltrlll 011 CONnn"".,OF MY CONIRACf on OTllI!n OOCl''''~Nf W1THnaptCT TO WHlet! fUll Ctl1r'lCAt! ),,^Y It 1&9U~D DR 1.',\" PlrlfAlfl, fliE IN~U"^r~cc ^"tOftDl!O DV "II! POlitICS DCScnrllE"O ..f;I1I!1N I! SlJaJIicf To ALL THIi fEAM!. VtClllSION8 AtIOCONDITIDNS 0'- Suetl rulft;I~o; AOcnFo..." ums SIIO'NN MM U^VE OCI:N "I:DUCfD 'h' rAJO e.....""! l'lt:" ,no '--.'- -.-___#_4'_ ____._ ll!! Nsn Tn', Of rNsun"N~e. PolICY Nw.cn C[NEMlllArnUfY xj CO\M:.tRl^L ClF.NLn^L lINJllFTY CMP91312 9 J . .- - J r.lA,~I' I.IM! ~J occu~ _. -"- - _. ~- -..- .. .h_. _ ~ '__'_ _...__ GC"l A'1n"~fJ^'l:: I.1Mlf N'PlIf;S "(;R "OllCY I,J1c?i loe AU10ItOtllt' UAlIlUfY OS/23104 ~ CQMnlNEn tINGLE lIMIT (EaItl:1denl) .. 1M" .1000000 1100000 -=- 15000 11000000 ~:= 12000000 1100<1000 -=-.-: . ------ ------ --'--- 1 ~~~~L___ ~~.!....- -'--- /\aD 1 .5000000 . 5000000--' 1 1 '----- ---- . poon. V 1N.IUHY (POt Pt'ton) BODll Y INJunv (VOtlCCldtlr1l) IIAorEAfY DAM~f lrttktltloflll' OTlft"'TliAN mfO OM. VI 0"23/03 I!AcH occunnENcl! AnD~lC. - 0~/2j/04 Y A _L~~~~ l!!:!I~~EA-E-'!!:.....tJVS:_ E l DI!;1!A3t:, POlICY lIMIT OUCflIPIlUt'f OF OPI:R..."OHS/lOC,lnONI' vtlOCltS lltClUtlONS AODI!O 8'( lNOORS M!:N Iln L P Prool of in~urano.. CEnIlFlCM~ 1I0LVEn IONS 1 , ----- --,-- 1 · -__-=-7 1 , CANOElLA TION TOWN 111 8Houlb AllY CJF 'HIli AllOY! DUCAlllD POUCrU 15 CNfC!LllD D!~OR! TIt! U"'RATIOtf bATITltCIltOf'.tIlI'.stllNU'....e.....l.NbUVotllOlI... 15 bA,"w.mfN Hone_ tll 'HI ttnl"'CAI.IlOlOln NAM,. t.TH' UN. a'" ~A",,^l T. DO s. .tQLL IMPaM JtO CMlUQ,AtlOH eft: UAbttH'I 0fI AH't kWfD lIfIoN 'nIt 1f411",.n. 'T' AOI!~'" on ......IIO/IIA Town of Bouthold lIighway oept Pllconlc Ln peconla NY 1i958 ACORO 2G (2001/001 o CORO CORPOR TIO DB8 -~_..~..,,' ......,.'...., .,.... "......I.~.....'., ,...\",loj~I"" ." ~1^,,,,,U. NMV ~UII.K lVOIlKElm' (;OMrtNMTION bOAItD CEltTlFCATE or l'ARTlClI'ATION IN \'I'OKI{KRB' COMI'ENIlATION Gll.OlJI'SEI.F'.INSUIlANCF; ..,-"If/l,:. .".- .._--L._____-:----._. 1.1 l.rrJ1 N~nl,' :'!nt.! ^(!tlH'''S IIf 1I1.(iIIC~1 rJIlh.: ~,Ir.rn~IHJlltc (the !iI,<,;\'1 ^{hla'u (llIly) 1;111;1;", rllllCn'JI I}fI "lJrlnc, (l,h.c S~:JlII:lfnl'lnn. Ny J 19t.tC -- '----0'_'-"_0_"_"'_-' Ill. '",'r'.:c,iwt: Ib!C (If MCIllh1'l1hil' 1,1 Iln~ Unlit I' rllhfic;ll~ rnlutl 0'"11/0.1 TIl I/UI/O.t f ',,'illnl,' "'mllher 01.1101<1.1.' -.-----.---.- I.:. "h~ l'lnrtlllo, rJfl11CIS 't, f.~rl:uli\'c omu IllnduJnJ (.)nly ctll:d: he'l If.n r~III1CI(. Dill II ;III c\chltkd III 1"( 11.,in p:\II"rl'S/ull1ccI. c:w;c1 --- .' ~hnl~' ,1nJ ^ddll''u tiC Ihe Enllty Rl'IIIU:~dIlC {1,"t~ lhh'.1 ,11 t"tnlrk,lil'lIoltk',) 111.\11 or 50,'lllh('lI,' _ 1t1::llI\;I~ lJl"Ill "HI':llcL,ne 1"'(j'/Ik.NY IIl)SR '--'~--'------ TI.i5 c(:t1in~'S 111M Ih~ 'JtI~lncss rdcrc N~\V \"llIk ShllO \V",k<,s'('~",pr.II' n"d 1,.,lid""""" III ,,,eh g,"ul' selr. 1I11'lIltid"nllllO to tho e,,'i1Y IIslod 0 '1 he G,oup Sclf-I"""er'~ AdmlnislI pMliclpnl11 Ihled in bOA "l:t" 1!<lll'ltf i1 ","""lIt11n of linn )'cnr r,o," the t1:l Ifll';J ITllijit-"f,! h 'In /Oll}(l!" ",IIM 1In1IIl.tf eJll 0 1""111".. /in:IIJt Of f:mtl 1";,11,, "i'1I' al,i/kntr ()f mitt,. nu," Nrll' YOIA SInl" WOlkers' CompcI/t, Ihtlln pCllolty of pcrJllry, I eullf rcferrllted nho.. ond lh.llhe hI/ Trlel'ho"e Nu,oher: 631.58 (is.!:!QH.!!!!.1l_____ ,- II UJ/Uj ir~llne In Grnup Id. b\l.,lncu Tcrcpltl,)flc Humbcr br bu..inc!\ ,ererellced in box "1:,,- GJI-2!HOOO Ie. NYS Unrtnpto)'mcnllnSlltllrlCO Omr1o)'ct RcrhtlnllDl1 NUlnb.:, or . - llu~ine~J rcrcltnrcl.lln hoJ >Ob- 111111102 19.21419 -- '1\ 1:I1~ II. tcde.:tIl!n1(1luYl:' IdcntUiaulClt1 NUlnt,.:, or DUllness ,crc":rto:c,t 'n t'llllllclurICll) 110-. -101- ulkd 11.)112942 - I'ux,( n( Cn"cli'tu (EndlY J. N,mo I.d Addlell or O'oop 5.1'.1,,,,,,,, TIlc[!kc:-COlf'ftUJI DO I- C:udlno1l Corp 10 Drhl~h A.U...flt:llt'lJl"d IAlh:lIl'1. NY 121 to 'ne~d nl...e In bo, "In" Is complying with the mindnlOIY eover.go lequllClIlents or Ihe :1I1"n l.ow os 0 I':tHicipnllng member of Iho GrouJl Self.lnsule' IIsled above In box '3' I",urll"ee Is slilll/1 fo,ce, The Group Self.IIlSUftl'S Adllllhl.llllot wlll,clld IhI. Celllnealo hllvo AS Ihe eeHilleale holder 1/1 box '2". ,lIor will nolify Ihe ,bu". cerlifieolo holder within 1. days IF UI. melhbenhlp of Ihe ,innled. (lh~'e nOlice. mny be senl hy regular 11I1111.) Otherwl~., Ihls Cerlllleolo Is v,lId for Ie r~tlj(ied by lil~ cronp 5elr~in,ulcr.u naIJrd",s '0 thc 1I1.o..e R"Itlc/lllfS nud II" blll/lless tifttolle..111I bO.T "In" cOl/l/lloeJ lu be 'n<l /r.\IIcd by ,,,, IClllfit-a'c Imlcltr, ,1,. lI/Isllle11 11I1111 "rovld. ,It. etJrt/flelllo hnlrle/' eflht/' n/lucl ",oal,It. bmll/cJJ I.t call1plylllg willI t/,. '1/011'/"'0')' rnvII'ogt teqltfrellle",., o/,lte II/nil LnU'.t y Ihallom an uulh"rb.d reprr,eul.t1" or Ihe Group llelt.lnSllter dllcs. referenred In hox "lu" hu Ihe cover.ge lU deploled on Ihls fOlln. ~,'iJlJJnJr.At~~~ I'll n:tl'lll! or AI htlfiud rcr'&:,cnl:ltivc t" the O,,",p Sclt.Jn,uIOf) 'j /... ~') tOr'lMlJ ".!t&lI..!kI!lr~lilIY9. 1.1918 - IJ.llt'l': (rrl . ....."_........."~........,,....,......~. '-. ..JI~....... ".~.... . . Date: 10/23/03 Transaction(s): Town Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Receipt#: 1 Permits Check#: 20698 Total Paid: ~ ~ ~5 Name: Utilities, Plus Corp 99 Mariner Dr Southampton, NY 11968 20698 Subtotal $65.00 $65.00 Clerk 10: L YNDAB Internal 10: 83021