HomeMy WebLinkAboutMiller Environ. Group for AMAC - Old Main Rd.
EUZABETH A. NEVillE, TOWN CLERK
Town of Southold
Soulhold, New York 11971 /1 C p
Phone: 516-765-1800 DATE ?If' -,c' I :1 19~
RECEIVEDOF:'/r),//",,, )~/f> {J. ltp/?(i'Pp "S,,-, $~(iO-
FOR: ~.... - /- . _ ''k ./'/I'.Iz"d::y-
'1~Q.Lr eyc<<-<').:<<'L~,~ :t&./,ry~'~#lh
o CASH
~!:CK # t.( 7'7/
RECEIPT
67953
L
BY:
.- i<JL~9f2"--C,
RECEIVEDOF:~eld-"_' ~~)
FOR: tma.J/'f,{;...,,,,,,-1'< ---yf!'I-;rr"'-/,
'--Tnt (j.J.L.O"7! <P-Uow).r/J, t '''y, .7'
o CASH
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EUZABETH A. NEVIllE, TOWN CLERK
Town of Southold
Soulhold, New York 11971
Phone: 516-765-1800
RECEIPT
f37955
DATE 9 (//k-
d/1 G/I(11 Idl $
I
/ ,-1 19 Fe?
/o() "
BY:
7f.. /{,
./ ? ({IIJI.;).Y(./
/
ELIZABETH A. NEVilLE, TOWN CLERk
Town 01 Soulhold
Southold, New York 11971
Phone: 518-785-1800
RECEIVED OF: ~ 1./( A I Lbl1 eJ
FOR: 0./>./1 (J" d r~ e;, ."/J-d~.~
/""7
;
o CASH
~HECK ff </1C;- /
RECEIPT I) 7 ~) 5 4
DATE YLV,C/ Ie" 19 p ;;P
&i"<jP ~_/.{,;..____ LA~-
';7q/c. ;/1:. .(J '1 'P;u.'d.h-, t';,c-~
.."/'7/( .
BY:
. --I~'{b(';L)~C
I
~
Issu.eingHighway Excavation Permits:
____.-Applic<intmust have Supt. of Hwy. approval &
determination of fees, security and maintenance.
______............__._.............. ,I
---.------'.'-...--
Iss.l.Ie rec.eiptshowing the three different fees.
l.op.y-page.-L&.~ of permit for applicant
__~p.y__RSl.9-e-L.2, 3, insurance and map for Supt. of
Hwy. and. transmit to him
Recor:d.in Black Book on three seperate pages.
.--'".-" .----....-..---....'. -
____..._s..tl.lP file.
Af.1ermc.ompletion (2-3 yr), obtain approval from
__.__. SUEt-,of Hwy. for release of maintenance and security
_.____.U'.llney. _I.fapproved:
Submit-voucher for total of maintenance and security
to acc.tg...depL...JQr audit. Money must come from
Agency _~._T.!:':I~t- Account. (T1.030) Speak to J. Cushman
confirm acc;1J.L..'.
Be sure_.~()._.I1~ve acctg. dept. give check to Town Clerk
o_letter.can be sent with check.
N.lL.QF .MONTH REPORT & CHECKS
'~. SecurJty & maintenance are given to the
...slep1. J9.Lgeposit into Agency & Trust Account
L_C~..does. monthly report and checks. Will
C!lLl?~_!i!!par<itecl out in the Monthly Report.
:
..--:------
File No.
/(,
/b
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.
"
Permit No.
REaMD
'JAM a me
ScuhaldTOWII~PLlCATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic. New York 11958
(516) 765-3140
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 m'a,ke, necessary inspections of the job site.
Print or Type
1) /1'1,'11.... E n\f"'COnM "'" 'h-J> G roup .5-3/1
Name of Applicant J
3 ''1 -'fqClC
ErJcu(u'dj Ave Po ~o" 6/0 Cc.I~ IVY
'Address .
/(qJ3
2) AM.Ptc I 1>, 0, 'i?xJ x ILj_~(,l,.Jti't.\x:'~-r- 1V\{__l.~cI.S=_~_,________,____,
Name of Owner of Premises Address
3)
Cross
, 'tL&l,. fl1.. Ii
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes. other Town permits may be required.
No Y
Ii) Builder's License No.
fl/A
Plumber's License No.
/VA
Electrician's License No. PI A
Other Trade's License No.--L1{~__._
~dii~
~ Signat of Applicant
d7/7y
I' Date
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 pel'mits 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)
7)
Tax Map: Section J)..;),
Starting Date:~ 1J..1fJl1
Block .-----Ld
. Lot.._. I
15
'J f'tf-ll--
.Completion Date A~v-y.
8) Work Schedule:
Completion..Qa,t,e,
1J I.7-J3L___
Facility Installation................................. '!t.;L J 98
, ,-
Backfill & Compaction.............................. ___fl/Q_I'!.~"_______n__
Pavement Replacement.............................. rvc Nt:
Phase
Excavation. . . . ..... . .. .. . .. . .. .. . . .. .. ... .. . . '" . . .
9) Under which authority is the application made:~/leA 6"nv';<<"'~l~r~
10)
Estimated Cost of Proposed Work: $
:,l()OO
11)
Remarks: fl.r"",,) :~(J-U, ,~);\\ no.:!:. \u d;",\-c<.A.W ,v.'Ie ~;n~
v.1,"\" (0-("-"", ~ IJnd!!.b.. u\cl (Y\n~/Vo .Jl,.o.ad..~...20_\--< f"C~"""5)
D-39
Page 1 of 3
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12) Insurance Covera~: (Attach copy)
a) Insurance Company: l'ZOWA\- E.. ~:\\ A:;s<l<,'''~e~
b) Policy #. Se'<J'(.Ar< 0 - See ,~1i~ C e." ,'-f-'ca..\v,
c) State whether policy of certification on file with the Highway Depart-
ment: 11M
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
a) Surety Bond or Certified
total amount of $ /0/) ~
,
b) Maintenance Bond provided:
Check o2OcJ ~provided in the
2 years or
3 yea rs
14)
Fees for
A1.
applications and permits:
~A /Service Connections
o.
A2. ~/Additional Excavations same service @ $10.00 = $
No.
Basic Application Fee........ $25. 00
excavations @ $20.00 = $
E.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
Nlr'o I.f. @ $0.10 - $
~
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00
rV / Po I. f. @ $0. 30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
(VIA I.f. @ $0.50 = $
Additional
tI~A Utility Repair Excavations @$10.00 = $
o.
NIp, Repairs same service @ $5.00 = $
Additional
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 Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with this application.
DENT OF HIGHWAYS
SOUTHOLD, NEW YORK
/- f~ 9f'
I Date
Received by the Town Clerk I / g- J r K
/ Date
Permit Issued I ~a~t~/tK Cllf Permit No. / /,
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.
0-39
Page 2 of 3
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Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
Inspection Date
Findings (use code)
Appl icant Notified
1st
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 to repair
0-39
Page 3 of 3
JAN-07-1998 10:07
515 249 0025 P.04/05
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ENCORSl:MSN-:' FOR
MOTOR CARl'll!!'! POLICII!S O~ INSUlUNce FOR PUliil.IC LIA31L.ITY
UNDEi'l saCT10NS zt AND 30 O~ THS MOTOR CARRIER ACT OF '9<30
Form ~C;C(cvl!C::
CME! NQ. z~z.s-..:c:--
~s~.d~ Mille~ Eavi~oa~eaeal Grouo . 660 Edwsrds Ave.. Calv.reoD NY
NYC. NY lOOJ6
O.tee: at L l 77 A v e. 0 f Chit A me 'r' f {'O :t. ~ltnis ? 7 : h. day Of 0 e t: 0 ~ e r . 19 9;
At:'!l!n<ling P,oIi!",.NO. CA 27 7 - 2067
.'
Elllleli\oe Oate LO /0 1/9 i
Name ot Insutatlce Company C&I/AI!: ~nvi P<?"ftlQll"l ~~ 1
Telephone Numbe' ( 2 12 ) 4 78 _1 ? A 1
. CQunlersigned by
.a..1C_...ac-.- lJ _4 .
Th. poliq 10 wllic.'I lIIis .nd_enl is alladled provides prlmaly or uc_ iNutan.... u inellcate<l by :.1][... ler lIIe limiU shewr.;
i:l This insurance Is primary an<! lIIe company lIh8ll not lie n8llle tvr amounts in e_ 01 $ 1. 00 0 . 000 fer each acc:c.nt
o This insuranc. is ex_ andllle company sIIaII not lie Batll. for amoums in .xcess of S for each acelcen:
in e_ of lIle underlylnglitftit of S for each acddent.
WIIen_ rwqund by !he Fed_ WlghWlIy Adminlernlllcln (l"HWA) or IIIe Jnbnst8It Commerce Commiaslon (ICC). tile company a;ree!
10 f\IrMh UIe l'HWA llI' trle ICC ..~ of SlIId polley and.. ill ~ The COIllPlIIIY MIa agr_. upon _hone teqwes:
b't' atl authOriZed ~oI trle FJoIWA Of itle ICe. lO vwrIfy Ihat _ policy ia In IMe &I of a particular elate. .
Cancellation of 1Iu. ~emtnt fNY lie eIfecIed by the campeny or Ihe ineurecllly gMng (1) lIlil'ly-f\ve (3S) days IIOlIce In wrillni
lO the ollter perty (aid sa da)S notbr lO commence from !he cIat.e !he noIbIllI 1IIlIiIed. proof 01 rnalllflg sIIalIl:le .ufffcient ~f 01
notice), atl4 (2) if ltIe lntureclla suIlje;\ 10 lIIe lCee jurlsdicdon, by ptO'IicIing lIIIlty (30) days notice to tile ICe (said 30 clays nolle.
10 ~",menc. from Ifte e1a1lt the notiClt 1II1KeI~ by - ICe at llII office ill WaIIinglOn. D.C.).
MPINlTlON$ AS useD IN THIS l!NOOfISlMViT
ACClDen' InCIulIeS ~ Of .~.le(f expolKft lo c:oncpaon. ~, Ofclesllucllon of n.tural l'9lIOl.IfC9$ arl$ing out 01 ltIe ace;.
which resub In tlOCIIIy Injury. .,.operty ~. or erMcomi\ent8I ... clIecharge, IIItp .1181. reIeue or WClIP9 inIl or upon lhe lanC.
damage which lhe Insured IltilIIet expeclId nor in!encIecI. atmoIjlhere, WIfetCOUl'Se, or body 01 wat.,. of any commcdir,
. . ' nntpoMdlly.llIOeIltcurler. '1'lIUllllll.inclucle.lJtellOStafre~
MOTOR YlEHICUi _ eland l/9IIide. 1MChine, truck, \I8clOt. ancIlhe _ of nec...try measures taken to Illlnimlze or mIIlg&l~
trailer. or sernilraiiotr ptOpelled Of clrawn by mecIlanIcaI power and clMlage to IIum8n !laIlII, IIIe natunIJ environment, fIlrh, sheIlllsh
used on a highway tvr .ttanapcllllllQ propetty. or any CClmlIInatIOn and wiIdIifw. .
'lIIlreof.
, . di PflOPIRTY DAMAGi m.ana damage toorfOSSofuseoftangil:l.
1I0CIL Y INJURY m.- injury 10 !he body. ~. Of - u_ pfOptItty.
to any pet$Qr!. InclucIIns dealh -Il/ng from any of thft.., pueLlc L1A8lUTY __ rl8bUlty for bodily Injury, property dam.
ENVIflONMl!NTAL ReSTORATION - restilutIon fl:lr ~.. 8l!e. and ~laIlWStOmon.
The insurance policy to wIlic:Illhia ~ it .tUIched ptO- thereof. IhaIl reIilM tile company from liability or fnlm lIIe pay.
viCes .UlOmOblle Iiabillty irlsufanCe and III _~ to _we ment of ."y final judgllleflt, within the limits of IiabiRty he,e;"
COI7".Qllanc:eby1he~ wllhinlhellmilulllleclherein....molCr dacrille4.InMP~ olllle r",anciaI concIillon. inaolveno:-/ cr
carrier of ptOfl9tty witII s.c.,. 2t and 30 of lhe MolOt ClIrrIer. bankruptqt of file inatnd. How_. an _. conditions. ar.c
AGl of lHO and me ruIft and regulaliona of lhe Feder8I HigllwaY limitations in lIle policy 10 whicn tile endorsement is attached "".:
ACministration (l'HWA) and the IlIlerSlIle CommetCe. CornmrloilOtl remain In lull Ion:e IIICI tlf<<:t IS bindlflg ~n lhe'm.urld anc
(ICC). !/I. comllllly. The insured agre.. to reimburse the comllat!y lc,
. any paymenl ma<le by the compatly en account of I/'.y ac:ic!!r:,
In CQnside,*n of lite "remi"", staled in lIIe policy 10 wll,c11 fhja clain'l. or suit ilMllving. breach ollh. lerms 01 tlle poIlc,. and rc,
.r.ccrs.~.nt is ar.aclled. !/Ie insurer (the company) ~rsll$ :0 pay, any pay...,,,n! tIIalllle company would not have been obligalt!! ::
wilhin th. Iimill of lialllllty desc:dbed herein. ~ final i~dgmenl make und.' tJ'I'lltllVlslons 01 the pellCOI excepl for 111. 2!;,..mer'
recovered against lit. inaured fl:lr pulltlc liabIlity resulting !'Om containlld in tJ'Iis endorsement.
n..gUge"ee in tJ'I. OIl9ratiOt'l. mainlltnanc:. ~r IISlI 01 molOr velllcles
suerectlO th, financial responSibility reqwr.ments of S.oc:t1ons 29 II is Iutt/le' un<lel'SlOOd and ayreec I"'t. upon lailurv of the CQr:'"
anr.: :'0 c; lIIe Motor Clrrier Act 01 .1i80 reiarCll~SS 01 WII~lh.' or pany 10 pay any f:r.al jUC:;r:"~nt 'ecovered ~sl tn.. ins..'1Id 2<
no: ..ach mote. vinicl. is ,pecifically d""""=:..:t In IlIe,polley lInel provided he"in. :lie Jud<;mot"t crsc:':or m.y maintain an ac~cn ,"
....h..!~... or not .uOh nl!Ol~enc. occurs on any roule or :n any lern. any ;:ou~ 01 cempelent ju,isc:iCli..n again.: tile company :0 CO"':;
10~/ a..:hc,'i'ed to be .''','!d by the insured 0' oiI......h_. s...ch .~..h ;:aymer.:.
i~s:'::!r"':e J; is ~ttC~9<:. fer public Jlabilicy. ~-i$ nOI af;ply,to in. . . ..
ju,", :0' c, ceatll of the ,ns.;reel's _Illeye..s wnlle '"".lOalOer.: In lfle The limIt. at tn. company'. JiaQilir,lo' Ihe ","eu~,:s ;:r!$:":"~ '
COUr3a 01 tlleir "'1l;:lfOymenl. or propeny U'lItISpOnect by lIIe Intur'!d. 1II1. enclQrsem.nl apply se;:ar31.ly. to each acc:cer.:. anel 2r.
t:",'gr:Sled all car;o. II is undemood and agreedlh.1 nO conc.. ,,'D,,-'11 uneler cr.. poll..., ~eca"se 01 anyone accicent s/'lall nc
tlCn. ~'cvlsion. supulatiCln. or limitation contained on Ihe ;:011,,,,. thIS oP'l'31a:o red~ca tn.liaCilirl ot 1M. comj;:any fe, tile ~aym.el :
en4e,...",,,nt, or any olller Incors.."enl lIIereon. or vicllatfon fir-at luc;m.nts resull;n; "01'11 an', etM, a":::C~nl.
Tn" .'/1:rOf Carner .Act allMO' re<;uitltS timirs 0' ti"at!ci~ respo,,~bility ~rctin9 :0 the ty;:e 'J( earr1aC;9 ."d CQmmodiC"J tr&"$~CI..
~'I 'h~ ""o'~, 0'3'';.', It is the MOTOR CARRIER'S oth;alion 10 Ot:lla'n tM '~uir~ limits 01 :inanc:al ''''consit:ilir/.
... :. _..... __." _ r-:!, ,.,,-,,: -:-~rq,,,,,, '-J'lol ,:",:...; -::::/'E_~-::= ~lr.r::: ro.r=: ...,,....- :::::,....1;lf'..c: ,..~. ._-,--.
JAN-07-1998 10:07
516 249 0026 P.03/05
., MEMORANDUM
1{ 7{1998 1I11III
..ZMPORTABT ROTZCE..
--------------------
"'lB. MY 'TATB II1BDRAIICB OUT. BAS STATBD TDT (1) THIS CERTIFICATB
or tllSDRAIICB PROVIDES nZDDCB 01' COVBRAGB III LIBO 01' All ACTUAL
con 01' THE InDRAIICB POLICY; (2) THIS cannCATB DOES BOT UElID,
EXPAND OR ALTBR AllY or TBIl TBUI 01' TKB IRSURABCE POLICIES ADDRBBSBD
BY TBIS CBRTII'ICATB; AND (3) THE WORDIRG 01' THE REFERDCED
IIlSURARCE POLICIBS, AJID IIOT TBlS CBRTII'ICATB. WILL COIf'rIlOL. III THB
B'lBIfT OJ' AIrY IIICOJfn.'l'DfCY OR COlfJ'LICT BETWBBR THIS CBRTIJ'ICATE
AIID DB DPLICULB POLICIES 01' III.DRUCE. A COpy OP TKB DPLICMLB
POLICIB' 01' IIISURAJlCI WILL BB nOVIDJilD POR IIlSPECTIOII UPOII WRITTBIf
JlBgUJilST. "
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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.
~.
~.
. /
"J;i;gt;;JC'iIi"""""".,.,.,.,.......... "."""".,.,.,...... , 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
. POLICIES BELOW.
Robert E Bill Assoc Inc
814 Fulton street
Farmingdale, NY 11735
(516)249-1000 FaX(516)249-0026
COMPANIES AFFORDING COVERAGE
COMPANY A Commerce & Industry
LETTER
COMPANY B **The state Insurance Fund
LETTER
INSURED
!!9Y'MII~f;tnnnm':'tJt;: ",:ntWi:tnntWlntt:
THIS IS TO CERl1FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOlwtTHSTANDING 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
COMPANY
LETTER
vt~;.,.;~ D
:lc:"",~;.,.;~
. LETTER E
C American Int'l. Underwriters
Miller Environ. Group, Inc.
MEG Environ. Services, Inc.
538 Edwards Avenue
Calverton, NY 11933
...COpy
.. .. .. .. fORYOURlNFORMATlON
co:
LTR
TYPE OF "SURAHCE
POLICY NUMBER
POLICY EFRCTJVE ...:~.~~..~~....
DATE (MMAJDt'('() . DATE (MMIDOIYY)
LIMITS
10/01/9710/01/9~
GENEFW... AGGREGATE : $
PAODUCTS-CQMP/Of' AGG. : S
PERSONAL & ADV. IN..lIRY : S
EACH OCCURRENCE . .. :,~,.
FIRE DAMAGE (Anyone fife) : $
MED. EXPENSE (Anyone person): $
2,000,000
. 1, ()C)O,O()O
1,000,000
1,000,000
50,000
. .. ...5,000
A QENERAL 1WI1UTY
X \.~~RCIAL GENERAl. LIABILITY
. CLAIMS MADE ! X : OCCUR. :
: O'NNER'S & CONTRACTOR'S PAOT.
X.. XCU Included
Gl3409541
'AUTOMOBILE UABILITY
A' X 'ANVAUTO
..,: ALl OWNED AUTOS
....l SCHEDULED AUTOS
~ HIRED AUTOS
.. ...: NON-OWNED AUTOS
: GARAGE LIABILITY
X MCS-90
CA2772067
COMBINED SINGLE
LIMIT
. 1,000,000
10/01/97 . 10/ 01/99..o~I~~I~.JlJR~..
(Pel person)
:$
BODILY IN.AJRY
(Per accident)
:$
PROPERTY DAMAGE
:$
,....................................
: EXCESS UABILITY
A: X : UMElRELLA FORM
: OTHER THAN UMBRaLA FORM
BE6061558
EACH OCCURRENCE
10/01/97 .10/ 01/98AGGREGATE
. 9,000,000
., . 9,000,000
B
WORKER" COMPENSATION
AH.
EMPLOYERS' UABIUTY
8912925
...X_.:,..~T~~!.~~ LIMITS
10/01/97 · 10/ 01/98.EACt<ACCIDEtfr
DISEASE. POLICY LIMIT
DISEASE. EACH EMPLOYEE
., 100,000
. ... ..500,000
'100,000
OntER
CContrcts OpS &
.Prof Services
COPS7618962
0/01/97 .10/01/98 Ea. Loss
Total Losses
1,000,000
1,000,000
DESCRIP110N OF OPERAnoNSILOCATIONSlVEHICLESlSPECIAL ITEMS
B**st Fnd: WC info. for record only. Ver. Cert. has been ordered &
will be forwarded directly to your attention. RE: Town of Southold
included as Add'l. Ins. for Hway Excavation Permit of AMAC. Location
Old Main Rd. Mattituck New York.
:I; .....llJ!9!l!i'i:!!~~P..... .\\,ttiHti:j '.'."'.'8;;""'.".,.....'"",,',',',', .. .,.",.,.,.,.,.".."",'\\\\\"",.,\ttti:ql\....pm;lil\D9!'ft"'.","'.","'.'.,....
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELlED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
Town of Southold
53095 Main Rd. Attn:
P. O. Box 1179
Southold NY 11971
County Clerk
I:::}AUTHORIZED REPRESENTATIVE
~d'. ~~
~Aj;(!I~AjjQ~j~
Aj;Il!lQ@l~Rt!lililt@
.;.,.,.,.",.,.,.,.,.",.,.,.,.",.".,.,.,...""
.............. .
,;,:;:,;,:::::,:::,:;::,:~;::,:;:,:,:,:,:,:::,:".,.;.,.'.'.',' , .
......................,....-,..
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JRN-07-1998 10:08
516 249 0026 P.05/05
.f MEMORANDUM 1/ 7/1998 1_
'owa of 'outbold
S30 biD ad. Attn: Couty Clerk
1'. O. BOZ 11711
'outbo14 BY 11971
J.nu.ry 7, 1911.
The state Xn.urance FUnd
159 Bo. nanklin Itr..t
Bemp.t..d, BY 11550
aK: Kill.r BRviro....t&l Group, 1.0.
Polioy .0: .912.25
Bff.ctive: 10-01-97 throuqh 10-01-9.
a.utl_en:
Pl.... i.sue a certifioate of work.re' compen.ation per the
attached. Than you
V.ry truly your.,
ROBOT B. BILL ASSOCIATBS, IIIe.
~~~
Robert. B. SiU
pr..iO.nt
00: *In.ured
TOTRL P.0S
. 12/31 '';11 13:17
ID :LmIERFAX3800
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Date PrlntlId
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ContraCtor rum.: MILLER EIMROMENTAL GROUP INC
Fall Number: 51&-369-4909
Contact:
Phone: 51&-369-4900
Call Center: pee 1 Telephone Gas
Cable IV
Electric
PubIc VIhlrk
0100175 OW MAIN RD
0100174 7400 MAIN RO
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