HomeMy WebLinkAboutNorth Eastern Elec Serv - 7805 Oregon Rd.
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permit No. S 8
File No. sg
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765-3140
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 mlake; necessary inspections of the job site.
Print or
1)
U/,pt.
59/ -A ~'c d(
Add ss
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Address
1'201
~rh 11 J;If j';//
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3)
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4)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required. -
Builder's License No. -4fi;5l' - & - Plumber's License No.
Electrician's License No. f'~5g-€
Other Trade's License No.
~7~
p:' Signature f Applicant
~.... ..(- "t:>
Date
5)
a) Attach plot plan showing location of proFlosed excavation and relationship to
adjoining premises or pUblic streets or areas, and giving a detailed descrip-
tion of layout of excavation.
J)ttach all other necess<3ry permits and licenses for this project.
Work covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
Tax Map: Section 95
b)
c)
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, Block
, Lot
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Starting Date:
Work Schedule:
Completion Date
Phase
Excavation....... ................. .................
Facil ity Installatioil.................................
Backfill & Compaction..............................
P~vement Replacement..............................
Under which authority is the application made: ~I/"
Completion Date
s- / r-()()
C-- .)6
<:-10
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o -F '5 0 u ft,,, IJ.
Estimated Cost of Proposed Work:
Remarks:
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p~; ~/
$ 0000
X (loo.J ~ J o.~
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Page 1 of 3
.
12)
Insurance Coverage: (Attach copy) 4.J
a) Insurance Company: p(f)
b) Policy # /fJ1-nq,'tJ5{IQ
c) State whether policy of certification on- file
ment: dO
.CNA
with the Highway Depart-
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
total amount of $~
b) Maintenance Bond provided:
. --" C7'=9
0ClO, - provided in the
/
2 years or 3 years
14)
Fees for applications and permits:
A 1. /Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
~
Basic Application Fee........ $25. 00
excavations @ $20.00 = $
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I. f. @ $0.10 - $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I. f. = $30.00
I. f. @ $0. 30 = $ (~O (m
Additional .
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
f.f. @ $0.50 = $
Additional
No.
Utility Repair Excavations @$10.00 = $
E.
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: ~ ~-uA71A/lJ ~h~..-;::d ~.Jwc,,; ..M..u
in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
c. - ?~ (E)
Date
Received by the Town Clerk
Ie /; 'f/oO
. Date
Permit Issued ? /;r!O()
. 0 te
5'8
Permit No.
Note:
Permit expires one (1) year from Date of ,Issualjlce.
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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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 Bell Atlantic and L1PA have been notified ,in
respect to the application for an Excavation Permit in th~ Town of
Southold.
--:t
A C08[)_ CERTIFICATE OF LIABILITY INSURANCE I DATI \1AIIDDm')
M/ll/OO
._.~-_.... THIS CERTlRCAT! IS ISSUED A8 A MATTE~ OF INFORIIA'I10N
-..
I.rtow In.urlne. A.gency, I t\C. ONLY AND CONnRS NO RIGHTS UPON TI1E CEII'I1f1CATE
HOLDEII. nllS CEII'I1F1CATE DOES NOT AMEND, EXTEND OR
62C Sou'" second 51. ALTER THE COVEIIAGE AFFORDED BY THE POUCJES BELOW.
0.. Part<, NY 11729 INSUREIIS AFFOIIDlNO COVERAOE
631.2.:1-4745 "__.n ___ - n_.,. .....--..- .-..---- .,-..',--- --~--- --
........ l.;""ER A. CNA .._~--
Nwlh eaatam electllul servlcH. lnc. .....-- --_..
27 OWln lIun INSUfEFl: e: ,--" ~,_. .-.---.
Hampton Baya, NY ~Fl~RC: "-",'--'-' --------.,-
INSURER D. ...---...
I IlNSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HINE SEEN ISSUED TO THE INSURS) NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANOING
ANY R.OUIAEMENT. TE"M (IR CONDlTlON OF ANY CoNTRACT DR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. T"E 'NSUAAN 'E AFFORDED BY 1HE POlICIES DESCAtSED HEREIN IS SUBJECT TO All THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
pOlicIES. AGGAEG."T( UMIT~ SHOWN MAY HA"E BEEN I=lEDUCED BY PAID CLAIMS.
~ .--.. ~"~"~~NC~_ '"1 -.. -- ';;~-;"EA' ~ ""-Cnvr~y DPlMTiDi" -- .----~--.
A ~EHlAAL WBLJTY ~lI0871 01/26/01 01126102 .~ ~CURRENCE I 1,000,000
~ ~ME~IAI.. GENERAL..I ~llIn : ~R: O.AMAGE (Any OIW!I fll'e) S 1DO,DOO
i CLAMI MADE. l.:<.! OCCUR I L MED EXP (Anyone perllJl1) I' 1Q.aoo
t =__~~-== _ _:~-:-, t=A~:GA7' : ::::
~1. AGGREGATE, LNIT APPI.,~ PeR I PRODUCTS. CCHPIOP ~ . 1,000,000
X I POCK:Y r-1 're n:~l',(}C
A AUTOMOIIu 1..WJ1UTY
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my AUTO
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~AI'nON 011 ONRA""'&/LOf:AT1ONIIVIHtCLQ,'D,CWSIOftI ADDm IY ENL1OfIIfUlEltT'-"::IAL. PAOVI8IOH.
'T1Ie Town of Southold .. named .. .ddltkmn' Inawed.
COVEIIAOfS
-:-:- ALL O'NNED AUros
.-!.. SCHEDU~D AUTOS
-1 ~IAED AUTOS
~ N~.OWNEO AUf 0$
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ANY AUTO I'
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~ OCCUR [] CUIMS MADE !
R DEOUCTI6lE
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WOAkERI COWCNtA'nON .'HD
UIPLOYUlS' u..llUTY
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B101104102a7
01I26lOO
01126101
COMBINE.D SINQlE LIMIT
(Ea IlCCIder1t)
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500,000
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BOOll v 1tW~'(
(1"Ir peraon)
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BOoIL'r !N..UAV
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PROPERTY DAM.tGE
<p-r~lIWie
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AUTO ()tot.. y - EA ACCIDENT $
EA ACe $
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I OTHER TH~
AUTO ONlY:
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0\00
EACH ~co
....GGFl::OATE
, we 2 2_185
X~i1J/;.I..
EL EACH ACCIOENT
~.l.. DiSEASE - EA EMPLQve::
E.l. DISEASE - POl.ICV !,.!MIT
100,000
500,000
100,000
03115100
0311 SIOI
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Cflll1FICATE HOLOER
,
..J..! ' ....DOI'1'1ONAL IN$UMDi INIUAM t.nftR.
Town Of S6utnold
PO Box 1779
SollIhold, NY 11.11
CANCELLATION
StiOUtb ANY OF THe ABOVE ~m flOl.JCB... CANClLUD llIIOM: THE EXfIIIlA'fI)N
DA'T'! JHfftEO..., lHE. I88UlHQ INIUREft WLL E.NOEAVOA TO MU. ~ DAV, w..1TftH
NOncl! TO THE CIFITlllCATr. HOI.DmII NAMCD TO nil LIJIT, BUT fALURt: TO DO 80 8tfALL
...olE NO 08LJGA.T!ON OR LlAlIIJ1"Y OF ANY lC..D UPON THE INUIA. "" 'GfJITI 0fI
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HIGHWAY DEPARTMENT
Town of Soulhold
275 Peeonic: Lane, P.O. Box 178
Peeonic:, New York 11958
RA YMOND L. JACOBS
-------
----. Superintendent
************************************************************************
FAX COVER SHEET
FAX TO:
:JoHIV FUR."-o~rJ . ~LeCTf.ICIArJ
1\J DR. -ru e.P,$IC.e.N 6L.tc 1"e,IC AL Serv I ce S .II\I<!..
1
COMMENTS:
(jhluk ~r If)55
-ALfefNI- --:r;;C(}~.s
_ftot~L fCO({'~$ 4~,
~,u1k Yl\lJ
f 5x:: 'ul,jk S/i},45 "3~5. 93
SHOUL OU HAVE ANY QUESTIONS, OR PROBLEMS RECEIVING THIS
FA,,'( NUMBER:
---.:1;;)3- 3105"
Ob~oO
J
DATE:
NUMBER OF PAGES:
FROM:
SOUTHOLD TOM
~' of R"md L.
Jacobs
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FAX TRANSMITTAL, PLEASE EITHER PHONE (631)765-3140 OR
FAX (631)765-1750.
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From:
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Date: Ji'N),o Total Number of Pages: /
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Comments: -IJ~r) f)~/~~~2
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If you have any questions regard g this fax, please contact us at ~.
(631) 473-4689 or Our fax #(631) 331-7317.
.....CONFIDENTIAL COMMUNICATION***'*
This tra.DSmi8Sion is intended ollly for the indi.idual or entity to wbieb it is addressed, and may conWn
infonnation that is privileged, eonfident;al and exempt from disclOsure under applicable law. Tf the reader
of this eomlllunication is DOt the intended recipient. any disseminatioD, distribution or coPYWlI of the
communication i~ strictly prohibited. Tf you ha.-c recei~cd this communication in error, notify the sender
immedialdy by telephone and return lile uriginal to llS by' mail.
Date: 06/14/00
Transaction(s):
Name:
Permits #~ E3
1 Surety Bonds
Check#:66897641
North, Eastern Electrical Services
27 Quail Run
Hampton Bays, NY 11946
Clerk 10: L1NDAC
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 66897641
Total Paid:
Subtotal
$55.00
$500.00
$555.00
Internal 10: 12623