HomeMy WebLinkAboutReydon Dr & Ct
Date: 06/12/02
Transaction(s):
-'-;--, :
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1 Permits
Check#: 20012
Name:
Utilities, Plus Corp
921 County Rd 39
Southampton, NY 11968
Clerk ID: L1NDAC
Town Of Southold
P,O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
f [t:!J
20012
Subtotal
$45,00
$45,00
Intem.IID: 56708
1.17 1.10 II~ .F-'RI UU -l.S LH 51b 765 61-15
SUl..iTHULll CLER1\
QjI)I,il
Penni' N\..J-if;J
Fil~ N(1-~"~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
PeCQnjc, New York 11958
(5'ftl1. 765-3140
'-3(
l"_-~-'C-
.!'..F'r>LlCATION IPERMIT FOR H IGHWi\UXC,:\V ATION. AND REPAIR
APPLICAtION IS HEREBY made to the Superintendent of Highways of the Town
of Southold fOI- the iS$ltance of an Excavation Permit pursuant to Chapter 133 of the
Cod", of the Town ot Southold, Suffolk County, New York, and other' applica:Jle laws,
ol"dinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable Jaws, ordinances, codes and regulations, and to permit
authoriz.ed in:,pectors to make neCe$S81-Y inspections of the job site.
~~I)'F_~
IJ (j.TI LI T L E;5..._ P !-U~.~~!'3- p __'11.L_C.ou...n'1--K~ 3. 0( .--.S..Q(}'H'" MtPW 1./
Name of Applicant Address
21
Name of Owner oT Pr'entfs-es-'~-- ~~~_____u Address
3d~E.":L/;)'()&') .Dr'tIV c;- ... L..':iJ:L12J...2. c..'V" _SOL>' H~____
Work Descdption and Location- (Street Number, Hamlet, CI~OSS Street)
(;;;I) Is construction located within jS feet of tidal wetlands? "'Yes No~~
*If yes, otheln Town permits may be l-equired.
4) Buildel,ls License No.
Plumbm-ls License No.
Electrician's License No. Othel. Trade's License No.
.,------ ~_._-_..--
t,/dLr#1-
Signature of Appli <:lilt
J12_JLi '-'-= _2...vo t-
Date
5) a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises 01" public streets or areas, and giving a detailed dascdp-'
tion of layout of excavation.
b) Attach all Oth81~ necessary permits and licenses for this pl-ojt,~ct.
c) Work cov81-ed by this <;Ipplicatjon may not commence before issuance (,f a
Highway Excavation Permit by the Town Clerk.
6) Tax rVlap: Section , Block ___ _~, Lot______ ___
n Startlll~J Date;.-fl JU~_~~__Compjetion Date II Ju ~ c-
8) ~P!:J~_.?ch~-.?_ule;
Phase
Com~tlo_n Date
Excavation............ .
11)
Facility Installation......"...................... ______
Bdckfil1 & Compac-.tion...... ............. .... ...... ._~______
Pavement Replact"lrnent............... .......... ..., '_~""________
Under which authority is the application made:UtJl1.~ 's 1;;",,- ~l...e-l/fSIO<..--'
..
t=siilllidted Cost of Proposed Work: $__'1 POQ .
!(ema,'k" p(."W c...q~L"'-rJ-/ C:~~...,~, .~11'01<'.c? r.I-.J()r;:-L.
~..-n <'f7 I(,VD....iQf...<f:II<njS, - !<.O..,-? c..., W"-\. (!VU,.J., 0'->'-'(
oF. 1~5.-' /;, 10 Lt,C..4?e ()"IIl.-nlf:!, ()(;;l'iiOu-::;e....' 01'-/ ffJIII0c()<Jj-
9),..,
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D- 39
Page 1 of 3
OT UI3 02 FRI 08;-15 En 516 ,135 51-15
SOUTHOLl> CLERK
i4]Of12
,
12)
!nsur'ance Cover~E;:: (Attach copy)
a) inSllral1ce Company: S U 7Tf? ............ A l:r fZ /<.Jc-'I
b) Policy # eM P "11.3 -, .;l. q 3
c) State whether policy of certification on file with the Highway Depart
mont: V ~
dJ Coverage required extended to the Town;
Bodily injury and pl"Operty damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Secul'ity:
a) Surety Bond
total amount of $
b) Ililaintenance Bond pi'ovided: ~_,~~2 years or ___} year's
14} Fees for applicattons and permits: Basic Appl ication Fee....... ~
A 1. /Service Connections excavations @ $20.00 :; $ "'2.. 0 uO
-NO=- ~---
or Certified Check
-----.-J)rovided in ttle
A2.
IAdditional Excavations same service @
$10.00 = $__~
.114 c> V
10......- S;
B.
1;;10:--
Excavations 18" in depth or less:
0-100 I. f. = $10.00
__I.f. @ $0.10 - $__
Additional
C.
Excavation::. 1 all in depth to S'
0-100 I.f. = $30.00
I.f. " $0.30 = $
AdditionaC-
in depth:
D.
Excavations 5' in depth and over;
0-1001_f. =$50.00
1.f.0$0.50"$
Additionar-
E.
No.
Utility Repail- Excavations @$10.00 $
Additional
_Repairs same service @ $5.00 :; $
F. Notice to public utilities proof must be provided and attached to)
this application pl~ior to issuance of permit.
* 'io: 1.'
Authorization is hereby gi-anted to the Town Clerk of the Town of Southold tl)
issue a Highway Excavation Permit to;
in accOl'dance with this application.
C,- /11- C;;
Date
Received by the Town Clerk to -1/- t) ~
Date
Pe,-mit Issued fa - / J..:/L1&.____
Date
Permit No. --.l..{:j
~ote;
Permit expires one (l} year from Date of Issuance.
No work to start without 48 hour notice to the Superintendent of Hghways.
Pennit must be available for inspection.
D-39
Page 2 of 3
~.
iJ', Ill) II:! FRI on:'\13 fAX .516 i65 6U5
SUlTHOLD CLERK
QJUO-l
Highway Department
Town of South old
Peconic Lane
Peconlc, NY 11958
T['L 765-3140
'134.5211
DATE,
TO,
CASE NUMBER:
-This is to notify you that Bell Atlantic and LlPA have been notified in
respect to the application for an Excavation Permit in the Town or
Southold.
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om: Stephanie Ko~t At: James F Sutton Agency T >: Patti
Fax#: (631) 581./bO/ Date: b, / /UZ U..:l:b4 ~M I-'age z or.j
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP ID SKI DATE (MMlDDJYYj
OCEAN-l D6/07/02
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
James F. Sutton Agency Ltd. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
149 E_ Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 76 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
East Islip NY 11730 INSURERS AFFORDING COVERAGE
Phone: 631-581-7978 Fax: 631-581-7507
INSURED INSURER A Merchants Ins. Co. of New Hamp
INSlJRERS
Utilities Plus Corp INSlJRER C
North Hif'hway
921 Coun y ROad 39 INSURER D
,Southampton NY 11968 INSURERE
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 BY 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.
INSR TYPE OF INSURANCE ,"OLlCY NUMBER ~~i~C~~~~:~~E Pgiii~~=J~ON LIMITS
".
~NER.lLLIABILITY EACH OCCURRENCE . 1000000
. -
A X COMMERCtAJ... GENERAL lLA.ElIUTY CMP9137293 OS/23/02 OS/23/03 FII"lE DAMAGE (Any nile hre) S 100000
l Cl..AIMS MAOE [iJ OCCUR MED EXP (Any one person) i 5000
PERSONAL ;r. N)1I1NJ1 JRY $, 1000000
GENERAL AGGREC',ATE .2000000
~'lIAGGREnM;R~lIEn I PRODUCTS. COMPIOP AGG S 1000000
POLICY JECT lOC
~OMOBILE LIABILITY COM81NED SINGLE LIMIT .
ANY AUTO (EaafclrJrnt)
-
- AlL OWNED AUTOS BODilY IJ\LIURY
.
SCHEDULED AUTOS (pefprr~onJ
-
~ Hll"lEDAlHUS BODILY INJURY
.
NON. OWNED AUTOS (PMarcldent)
-
PROPERTY DAMAGE .
(PprarcUlent)
=r,G'LlASIlIT' AUTO ONLY - EAACCIDENT .
ANY AUTO OTHEI"l THAN EAACC .
---. ----
AUTO ONLY AGG .
=r~s LIABILITY EACH OCCURRENCE .
OCCUR o Cl..AIMS MADE AGGREGATE .
.
~ IDEDlJCTIBlE .
RETENTlON . .
WORKERS COMPENSATION AND I ~~R~~~~~S I IO~' ---
EMPLOVERS'LIAEIILITY
EL EACH ACCIDENT .
E L DISEASE - EA EMPLOYEE .
ELDISEASE- POUCYlJMlT .
OTHER
DESCRIPTION OF OPEMTION511.OCATIONSNEH1CLESJEXCLUSIONS ADDEO I!lY ENDO"SEMl!NTIS,.eCIAl ,.ROVISIONS
The Certificate Holder i.s listed as addi tional insured.
CERTIFICATE HOLDER j y I ADDITIONAL INSURED: INSURER LETTER: CANe ELLA TION
, TOWN181 SHOULD ANY OF THE ABOVE OEsCRlBIiO POLICIES BE CANCELLED BEFORe THe: EXPIRATION
OATil THe"1I0F. THIIIS.UINa lNSUI'lEJIlI WILL ENDl!AIIO" TO MAIL ~ DAYS WRITTEN
Town of Southold NOTICE TO THE C."TlFICAT& HOLOIiR NAMIiD TO THIi LEFT, BUT FAlLURII TO DO SO SHALL
Highway Dept IMPOSE NO OBLIQATlON OR LIABILITY OF ANY KINO UPON THE INSURER. ITS ACENTS OR
Peconic Ln
Peconic NY 11958 REPRESENTATlIIES.
A~N'tJ.' ~"
,
ACORD 25-1; (7/97)
@ACORDCORPORATION1988
om: Stephanie .Koti At: James F Sutton Agency T l: Patti
l"ax#: (b,:H) t1lH./t1U/ wate: tli IIUL U.j::J,+ nVI r'i:lge .j 01 .)
'.
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 polley, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute 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 25-5 (7/97)
.. .
Date: 06/12/02
Tr!l,"\saction(s):
":' ~(!
1 Permits
Check#: 20012
Name:
Utilities, Plus Corp
921 County Rd 39
Southampton, NY 11968
Clerk ID: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
20012
Subtotal
$45.00
$45.00
Internal 10: 56708