HomeMy WebLinkAbout2995 Eugene's Rd
Highway Department
Town of Southold
Peconic Lane
Peconic, N.Y. 11958
RAYMOND L. JACOBS TeL 765-3140
Superintendent -734-5211
DA TE: 1/)..1/tJ).
TO:
CASE NUMBER:
/ <(0 ;).. ~3
This is to notify you that Bell Atlantic and L1PA have been notified in
respect to the application for an Excavation Permit in the Town of
Southold.
cf~ If. ~
Signature of the applicant
J., & M. Long Island Inc.
POBox 2507
Southampton, NY 11969
Received $ 55.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
. .
RECEIPT #158
1 - Permits on 02/04/2002.
Thank you.
'"
10)
Permit No. /SIJ
File No. IS!3
TOWN OF SOUTHOLD
HICHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(i0$6) 765- 3140
"-31
APPLICATION/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 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to make~ necessary inspections of the job site.
Print or Type
1) ~11 Lo>\ JT/':;lId c. ~a I]~ )..f'07 Sc."~4J>1 i kY. /19C
Name of pplicant A dress
2) 7),6111<'.u Go-e//,,. ;:>'0,&. //<f'it. C...tcJ.&>jV~1 MY. //93!i'
Name of Owner of Premises ' Adaress
3) (; ''iel. '"hiD tM"d~ rC<f(d 4t J.99s E" t.,; Il.d .lOGl/f /}C.
ork Description and Location (Street Number, Hamlet, Cross
(a) I s construction located within 75 feet of tidal wetlands? *y es _ No \(
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No. P4/ /?I"
Electrician's License No.
Other Trade's License No.
5)
a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation.
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.
/CltX'/ - t><f '7 - 0 3 -;..0 I
Tax Map: Section , Block ., Lot
6)
7)
8)
Starting Date: .2/3/0;;'"
Work Schedule:
Completion Date S'IMIZ d<::..y
9)
Phase Completion Date
Excavation......................................... I.t/c,r/.... ..,; /I (c.mMJltc4'
Facility Installation................................. ">'leA he u.":f1I(?t~
Backfill & Compaction.............................. G". re, nI Q d ~)/ _
Pavement Replacement............................. '~C.J oa ve hi. e^' f ' IN ,'lI 4E>
, (..1
Under which authority is the application made:
Estimated Cost of Proposed Work: $
6~OO~
f/.ir /ur';;,f~;IJ h~ a
,
~rvll~ ...., 1 Tv f, t. ,(de. ~'"
p/" w,-; J'e
11) Remarks: Tit! ...."rh cDvpr.f1P{
,-1 r~r/d~AI,,f /
Co" "p/",< ft ..,.. i tj
7'b rA~ rOt(
D-39
Page 1 of 3
~
12) Insurance Coverage: (Attach copy)
a) Insurance Company: ;::;"/J'_ld~~c.p!A/q rJ"^.f1(,;.
b) Policy # C ~05r-~'7 q f
c) State whether poli~YI of certification on ~i1e with theJ I-!ighway Depart-
ment: c./lr-f.l'lC.ll.1t t;.rt:~)>o.n'lJtyl., 'IJ..t 4/1/J/'i."r'<<1\
, I , ,
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13}J Security:
"
a) Surety Bond
total amount of $
_- b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
3 years
14)
Fees for applications and permits:
A 1. I IService Connections
~
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ).0.00
A2. I IAdditional Excavations same service @ $10.00 = $ 10.ocJ
~
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I. f. @ $0. 10 - $
t i .
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I. f. = $30.00
I.f. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 = $
Additional
E.
No.
Utility Repair Excavations @$10.00 = $
Additional
Repairs same service @ $5.00 = $
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *
Authorization is hereby granted to the Town Clerlj; of the Town of Southold to
issue a Highway Excavation Permit to: 9 I Yr) ~!! J.,,//--1~' ~ ;
in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TO~SOUTH~ NEW YORK
0~ ~ . ;W
dc2-CJ/- cJ~
Date
Received by the Town Clerk
cf} / <J~ 2-
, ate
Permit Issued '10/ ID 2-
~, Date
Permit No. / S 8
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
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'. New York State Insurance Fund '
Wo1'ke7:t C~tm &- Disability 1klIejiJs Speciali$t!l8;nce 1914
8 CORPORATE CENTER DR, 3RD FLR, MELVILLE, NEW YORK 11747-3129
Phone: (631) 756-4300
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
J & M LONG ISLAND INC
POBOX 2507
SOUTHAMPTON NY 11968
POLICYHOLDER
J & M LONG ISLAND INC
POBOX 2507
SOUTHAMPTON NY 11968
CERTIFICATE HOLDER
TOWN OF SOUTH OLD
PECONIC LANE
PECONIC NY 11958
POLICY NUMBER
I 867119-0
CERTIFICATE NUMBER
526571
PERIOD COVERED BY THIS CERTIFICATE
04/27/2001 TO 04/27/2002
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 867119-0 UNTIL 04/27/2002, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER
FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE
POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, EXCEPT AS INDICATED BELOW.
IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/27/2002 IN SUCH MANNER AS TO AFFECT THIS
CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER
ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION.
THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE
SUCH NOTICE.
THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICY.
NEW YORK STATE INSURANCE FUND
d~>>I7f1d1t...,.71
DIRECTOR, INSURANCE FUND UNDERWRITING
This certificate can be validated on our web site at https:/iwww.nysif.com/certlcertval.asp
VALIDATION NUMBER: 1053315109
U-26.3