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HomeMy WebLinkAboutDuck Pond RdTown Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 06/25/02 Transaction(s): Permits Receipt#: 20027 Subtotal $45.00 Check#: 20027 Total Paid: $45.00 Utilities, Plus Corp 921 County Rd 39 Southampton, NY 11968 C h.,rk ID: LINDAC Internal ID: 57616 Permit No.~ Pile No, ~___[ TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958 (~=~)~ '765 3140 APPLICATION/PERMiT FOR HICHWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of ~outhold for 1he 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 TyJp~ Name o~ Applicant ~ t~ Address '' ' N~ 0f Owner of Premises ' Address Work Description and Location (Street Number, Hamlet, Cross Street) (a) Is construction leca[ed within 75 f~t of tidal wetlands? *Yes No ~Jf yes, other Town permits may be r~uired, g) Builder's License No. Plumber's License No. Electrician's License No. Signature of Applica~'t 7) a) b) c] Tax Map: Section Starting Date:~__~ Work Schedule: Phase Excavation ......................................... Facility installation ................................. Backfill & Compaction .............................. Pavement Replacement .............................. Attach plot plan ahowing Ioc~tion of proposed excavation and relationship to adjoining premises or public streets or areas, and giving a detailed descrip- tion of layout of excavation. Attach all other necessary permits and licenses for this project. Work covered by this application may not commence before issuance ¢,f a Highway Excavation Permit by the Town Clerk- , Block , Lot 9) Under whicB authority is the application made:~J-'~-~ 10) Estimated Cost of Proposed Work: $ 0-39 Page 1 of 3 12] Insurance Coveraqe: (Attach copy} ~] Insurance Company:.(~U"~rot...~. c] State whether policy of certification on file with the Highway Depurt merit: Coverage required ~tended to the Town: B~ily injury and propert~ damage: $300,000/$500,000 B~ily Injury, and $50,000 property Oamage. 131 Security.: a) Surety Bond or Certified Ch~k ~rovid~ in the total amount of $ b) Maintenance Bond provide: 2 y~rs or ~ 3 y~rs 1~) Fees for applications and permits: Basic Application Fee ...... ~00) Al. /Service Conn~tions ex,rations g $20.00 = No. A2. /Additional Excavations same service $ Sl0.00 = NO. B. Excavations 18" in depth or less: 0 100 I.f. = $10.00 I,f. g $0.10 - $ Additional C. Excavatiorls 18" in depth to 5' in depth: 0 100 I.f, = 530,00 I.f. @ $0.30 - $ Additional D. Excavations 5~ in depth and over: 0-100 l.f. = $50.00 I.f, 0 $0,50 - $ Additional No. Additiohal Utility Repair Excavations 0510.00 : $ 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 Clerk of the Town of Southold to issue a Highway Excavation Permit to; in accordance with this application. DENT OF HIGH~'AYS UIHO].D, NEW/YORK - Date Received by the Town Clerk ~ ' c~-"O0~ Permit Issued ~ - l:~ ~'- ~ ~ PermitNo._/97 Date Note: Pel~it ~pjres one (1} year from Date of Issuance. No work to start without 48 hour notice to the Supevintendent of H ghways. Permit must be available for inspection. D-39 Page 2 of 3 - =..-...,.= ..~_.."-~-._~_._~_=- JOHN C. EHLERS LAND SURVEYOR 38 3g U D ~c~ Porv~ P~ LA "" 11958 :EGON 9 193,~ 9 AIRPORT COUNTRY HARBOR Old Cove RE A T P E C 0 NIC NEW SUFFOLK ACORD. CERTIFICATE OF LIABILITY INSURANCE OCE~/q- 1I 06/07/02 Jaraes F. Sutton Agency Ltd. 149 E. Main Street P.O. Box 76 East Islip ~Y 11730 Phone: 631-581-7978 Fax:631-581-7507 Utilities Plus Corp North Hignhway 921 County ~oad 39 Southar~ton NY 11968 THiS CERTIRCATE 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. INSURERS AFFORDING COVERAGE COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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 EY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS The Certificate Holder is listed as additional insured. CERTIFICATE HOLDER I Y I ADDITIONAL INSURE=; INSURER L~TTER; CANCELLATION Town of southold Highway Dept Peconic Ln ACORD 25-S (7/97) TOWN181 ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Jieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constrtute a contract between the issuing insurer(s), authorized representative or producer; and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon ACORD 25-S (7/97) Town Of Southold P.O Box 1179 Southold, NY 11971 Date: 03/09/07 * * * RECEIPT * * * Receipt#: 1119 Transaction(s): 1 1 Permits Reference Subtotal 494 $158.40 Check~: 1119 Total Paid: $158.40 Name: R & R, Construction 282 Line Rd Manorville, NY 11949 Clerk ID: LINDAC Internal ID: 494 03/07/2007 WED 1,3:29 PAX Permit No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT P.O. Box 178 Peconic, New York 11958 (631)765-3140 ~001/003 APPLICATION / PERMIT FOR ]~[GHWAY EXCAVATION AND I~PAIR APPLICATION IS H~REBY made to e~e Supermmnd=nt of H~h~ of ~ To~ of ~u~M ~ ~ ~a~ of ~ B~ P~t p~u~ ~ ~p2r g~ of ~ C~e of~e To~ o~ Sou~M. ~ffo~ ~u~, New Yor~ ~d o~r ~nble I~, ~d~ or rc~latio~ ~r ~e ~a~on ~em d~fi~. ~ a~ a~ ~ ~ly ~ ~ appl~b~ ~w~ o~, c~ ~ . re~ula~om, ~ ~ p~t au~o~cd ~rs m ~ ne~ss~y ~pec~o~ of~ job si~, Print m Namc of Applican~ Address of Applicaut Nsme of Owl~ of Prcmlses Address of Owner Work Description and Location (Street Number, Hamlct, Cross Slicer) (a) Is ¢onsm~ction located within 75 feet of tidal wetl.~l~? '~ Yes *1¢¥c.% other Town permits may b~ required. 4. Builder's Lkcnse No. Plumber's License No. Elcclricinn's Liccns~ Bio. Other Trade's License No. ] / Signntwc of Applic~t (a) A~ached plot plan showing location ofpropeeed excavation and relationship to adjoiniog premises ~ public s=eet or mea~ nmi giving n de4ailcd d~scfiption of layout of excavation. (b) Attach ali other necessary penn~ ~nd licenses for this (c) Work covered by ~ application may not commence bc fore issmnee of a Highway Excavation Pern~t by th~ Town CIc~k. Tax Map No.: Secgon , Block ..... Lot __ 7. Starting Date: Completion Datc: ' 8. Work gchadule: Phase Excavatio~ Facility Xnsmllation BaclCill & Completion Pavemcm Rcplacemcm 9. Und~ w~ch n~ is application ~ing n~de: 10- Es~mted Cost of ~po~d Work: $ Coml~et~om Date D-39 I of 3 03/07/2007 WED 13:20 FAX ~002/003 12,'hmmanc'cCoverage:(AlfschCopy) ~,,~/~c.~ (a) lnsuranc~ Company (c) Sm~ whirr policy of~m~ion ~ (d) Co~fie ~d extcnd~ to the 13. $~,mhty: (a) Su~ty Bond ~ Cerdfied Check ~) Mnint~mnce Bond ptovid~l: ~ 14. Fees for AppUca~on~ and i~.~d~Jts; provided in the total Amount of $ 3 years. $150,.00 $ $ s Excavations 18" in depth to $' ~ depth O-lO0 Lf. = $30~00; Add~t~oml i.£ (~ $0,30 D. Excavations 5' in depth and over 0-100 i.f. - $50.00; Additional i.f, (~ $0,50 IL Utility Repair Excavations ~ $ I 0.00 NO. Repairs same service ~ $5.00 Add,dona] · OT S I 'g, 40 F. Notice to public milifics proo£sm~t be provided and at~ached to this app~licauon pno~ to issumacc ] AuthoriZation is hereby ~ulted to thc Town Cle[k of thc Town of Soutlmld m t~ue a Highway ExcavatiOn perm/t to: in accordar~e with this tl~licatiQn, Dslc Receiv,d by thc Towa Clerk ~/~///~ 7 . NOTE: Pemit expires one (1) year flora dntc of ismance. No work lo st~t without 48 horn nolice to Soperi~tcndent of Highways. permit must Ix: available for inspection. D-39 2 of 3 03/07/2007 WED i3:~ FAX ~003/003 , Copy Dlstnbutmn: Highway Department Engineer (with page 3) Applicant Town Clerk (Original) Inspection Date INSPECTOR'S RECORDS Findings (usc code) Applicant Notified (To Permit Cleric) CODR Improper Barricades IL Improper Lights ST SanlCCn Ttcn 'uh ot Excavation UTM U~ble to Measure (due to backfilling) Duildia~ Unde~ Cortstmction WIP Work Irt Ptogrer~ DB Improper Baclr~l (~oo hi~l, not sufficicm) Inspector Holding for Final Scttlcment of Excavation RFR Ready for Repair D-39 3 of 3 ~1~ CATV ~METAL POLE O TELCO []TRANSFORMER ROOTE.' PROPOSED ,.BI"UE EXISTING: RED × DRO, ~ co.. ~<~JOINT USE ~ RES DROPS: PROPOSED: BLUE- EXISTING: RED {~ETER LOC r--~EXIS~NG PED [] PROP PED [] PROP LOCKBOX r"~J~ ~ODE ~ BW TAP ~"~ POWER SUPP ~] 4W TAP ~ MB/LE 0 SPLITTER ~'~ RLSER LENGTH ~o0~/~AP /HUB 'C-A--B'L' ~---T' "C-~ 'S' .500- .................... .650" -----= ....... ,750" · 750" FIBER