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Permit
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No.1. .
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TOWN OF SOUTHOLD
H IGHWA Y 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 regul~tions, and to permit
authorized inspectors to m1ake. necessary inspections of the job~ite.
!:rin!_or Ty~
1)
Name of Applicant' "~-~Address ---oo .-..-.......... . tJ'I
2) ".-f'~ ~ 5tL~Jo{l, 6?:JZ ~~~_J!t!.,.\!i~_,\'14',
Name of Owner of Premises Address I
3) ~ Sitff~ St;.. ~ LAUE
Work Description and Location (Street Number, Hamlet, Cross StreetT----- .-.....--.
(a) Is construction located within 75 feet of tidal wetlands? *Yes._.____No.X___.
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other
No.
Sig
__ e;;~r;ant--
~
5) a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descl'ip--
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.
6)
7)
Tax Map: Section
ll:S:: __, Block -----3____,.._, Lot___1__"
Starting Date:
._.___~_.. Completion Date
8) Work Schedule:
Phase
COll1pIElt.i{)~l Date
Excavation. .,. ... .. ... . . . .. .. . .. . .. .. ... . ... . .... . .
Facility Installation................................ .~_._.___
Backfill & Compaction.............................. .___.___
Pavement Replacement.............................. __.____. .
9) Under which authority is the application made: J.1.J!S ~_____.___...___ .,__
10) Estimated Cost of Proposed Work: $__~______._____~_____'n'
11)
Remarks:
D-39
Page 1 of 3
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12)
Insurance Coven~: (Attach copy)
a) Insurance Company:___________~_ _______________..__________.________._
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security: I
a) Surety Bond S'.CJD__or Certified Check yrovided in the
b) :~~~t:~:~~: ::n$d provided: !2u2 (y:a~ or _______3 years
14) Fees for applications and permits: Basi~fl!!(::ation Fee........ $25. 00
AI. IService Connections excavations @ $20.00 = $____________
No.--
A2.
No:-
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
_I.f. @ $0.10 - $_________
IAdditional Excavations same service @ $10.00 = $
Additional
C.
D.
Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00 t.
'7f:>"V I. f. @ $0.30 = $~ --- ~ =- z.~ 'll>ThL
Additional - I .r .t~-
.q~-
over:
~F
Excavations 5' in depth and
0-100 I. f. = $50.00
I.f. @ $0.50 = $
Additional
E.
Utility Repair Excavations @$10.00 = $
No.
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 To~e Town 01'0uthO.ld. .to.
issue a Highway Excavation Permit to:____ ~. _._____._
in accordance with this application.
J"ENDENT OF HIGHWAYS
SOUTHOLD, NEW YORK
. Jacobs
/0- n2?- ~_
, Date '
Received by the Town Clerk~..{?; /f'1':/'
Date '
Permit Issued /Jf7d"~.!f /ff~ Permit No.
Date
/1---
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
Pa ge 2 of 3
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'. -""'-O'Ant(MNiIDD;VV)
AMERICAN PHOENIX CORP. OF N.Y.
1211 AVENUE OF THE AMER I CAS
NEW YORK, NY 10036
THIS CERTIFICATE IS ISSUED AS A MAHER OF INFORMATION
ONL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
o
COMPANY
A Lumbermens rKemperl,
INSURED
COMPANY
Artca Drainage Corp.
Main Rd.
Mattituck, NY 11592
B
COMPANY
C
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTeD BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICA TED,NOTWITHST ANDING ANY REQUIREMENT, TERMOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MA Y BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
co I TYPE OF INSURANCE POLICY NUMBER POLICY EfFECTIVE POLICY EXPIRATION
LTR DATE (MMIDDIYY) DATE (MMIDDIYYI
LIMITS
, GENERAL LIABILITY
A ~."..:<.. ~ COMMERCIAL GENERAL LIABILITY
j'<< CLAIMS MADE [X] OCCUR
. OWNER'S & CONTRACTOR'S PRCT I
BINDER # 696276
GENERAL AGGREGATE I
10/24/97 10/24/98 PRODUCTS-COMP lOP AGG I
PERSONAL & ADV INJURY I
EACH OCCURRENCE I
. FIRE DAMAGE (Anyone fire) I
MED EXP (Anyone person) I
COMBINED SINGLE LIMIT I
!
BODILY INJURY
(Per person)
I BODILY INJURY I
(Per accident)
PROPERTY DAMAGE I
AUTO ONLY. EA ACCIDENT I
OTHER THAN AUTO ONLY:
EACH ACCIDENT I
AGGREGATE I
EACH OCCURRENCE I
AGGREGATE I
I
STATUTORY LIMITS
EACH ACCIDENT I
DISEASE. POLICY LIMIT I
DISEASE. EACH EMPLOYEE I
i AUTOMOBILE LIABILITY
R ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
n HIRED AUTOS
: NON.OWNED AUTOS
I ANY AUTO
I
I EXCESS LIABILITY
i UMBRELLA FORM
r OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
INCL
EXCL
DESCRIPTION OF OPERATIONSn.OCATIONSIVEHICLESISPECIAL ITEMS
CERTIFICATE HOLDER IS INCLUDED AS AODITIONAL INSUREO AS RESPECTS WORK
PERFORMED BY THE NAMEO INSURED, A.T. I.M.A. JOB SITE: SUNSET LANE, MATTITUCK
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
~_ DAYS WRmEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAD.. SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORlZED R.". PIilESENTATIVE/ I 1
,/ L..-.-. [---.- 003658000
I...lsm.IT;~.",-i~iiAC6BdCbWIRiaAti6Niiila
TARTAN OIL CORP.
P .0. BOX 10 17
MELVILLE, NY 11747
",ATTN:)AJ.AN.........
.1l000tt~~i~IU\"'"
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