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HomeMy WebLinkAbout1610 The StrandTown of Southold P.O Box 1179 Southold, NY 11971 Date: 04/08/11 * * * RECEIPT * * * Receipt~: 100165 Transaction(s): 1 1 Permits Reference Subtotal 693 $150.00 Check#: 561 Total Paid: $150.00 Name: On-line, Security Ltd P O Box 132 Medford, NY 11763 Clerk ID: LYNDAR Internal ID: 693 P~ut No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Pcconic Lane Peconic, New York 11955 (631)765-3140 APPLICATION / PERMIT FOR HIGHWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY made to the Superintendant of Highway~ of the Town of Southold for the issuance of an Excavation Permit pursuant to Clmptcr 83 of the Code of thc Town of Southold, Suffolk County, New York,' and otber applicable hws, orcli.~.~o~s or regulations fear the excavation herein described. The applicant agrees to comply with all applicable laws, orrlln~nceS, codes and regulations, and to peixnit authorized inspectors to make necessary impections of the job site, print or Tvce Name of Applicant Name of O~er of Premses Work Description and Location (Sheet Number, ~H'amlct, Cross Sheet) ~'~ -- (a) Is conslruction located within 75 feet of tidal wetlands? * Yes No · If yes, other Town permits may be required. Builder's License No. Eleclrician's License No. Plumber's License No. ~ t //~//~~/°f A~lica~ Date (a) Attochod plot plan showing location of proposed excavation and rchtionship to adjo~i-~ premises or public street or arca$, and giving a detailed description of layout of excavation. Co) Attach all other necessary permits and liee~es for this project (c) Work covered by Us application may not commence before i~suance of a Highway Excavation Permit by the Town Clerk. 6. T~x Map No.: Section 7. Staffing Date: Block , Lot Completion Date: ~"-- 8. Work Schedule: Phase Excavation Facility Installation Backfill & Completion Pavement Replacement 9. Under which authority is appiication being made: Completion Date 10. Estimated Cost of Proposed Work: $ ~ D-39 1 of 3 ,1~. Insurance Coverage: (Atlach Copy) (a) llmuranee Company: ,.J if (c) State whether policy of certification on file w/th the Highway Department/~'~/~' (d) Coverage required extended to the Town: / Bodily injury and property damage: $300,000 / $500,000 Bodily Injury, and $50,000 propen'y damage. 13. Security: (a) Surety Bond ~ or Certified Check provided in the total Amount of $ (b) Maintenance Bond provided: 14, Fees for Applications and permits: Basic Application Fee Al. /Service Connections excavations ~ $20.00 No. A2. / Additional Excavatiom same service @ $10.00 B. Excavations 18" in depth or less 0-100 i.f. = $10.00; Additional · i.f. ~ S0.10 Excavations 18" in depth to 5' in depth 0-100 i.f. = $30.00; Additional i.f. @ $0.30 Excavations 5' in depfl~ and over 0-100 i.f. = $50.00; Additional Lf. @ $o.5o Additional Utility Repak Excavations @ $10.00 Repairs same service @ $5.00 $ $ Notice to public utilities proof must be provided and attached to ~ application prior to issuance of permit. Date Received by the Town Clerk Dat~ Permit Issued q-~- Authorization is hereby granted to the Town Clerk of the Town of Southold to is~..e a Highway Bxcavation permit to: in accordance with this application. Permit expires one (1) year fi:om date of issuance. No work to start without 48 hour notice to Superintedant of Highwnys. Permit must be available for inspection. D-39 2 of 3 Copy Distribution: Highway Department Engineer (with page 3) Applicant Town Clerk (Original) 1 st 3~ 4m Inspection Date INSPECTOR'S RECORDS Findings (use code) Applicant Notified (To Permit Clerk) CODE IB Improper Barricades IL Imprope~ Lights ST Sunken Trench or Excavation UTM Unable to Measure (due to bacldilling) BUC Build/ng Under Construction wn~ Work In Progress DB Inpropcr Backf'fll (too high, not sufficient) HFS lmpector Holding for Final Settlement of Exc, avatfion RFR Ready for Repair D-39 3 of 3 ? ? / CERTIFICATE OF UABIUTY INSURANCE THIS CERTIFICATE I~ tS~UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOE8 NOT AJ:FIRMATIVELY OR NEGAllVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BEL(W~. THIS CERTIFICATE OF INSURANCE COE8 NOT CONSTITUTE A CONTRACT BE'I~EEN THE ISSUING INSURER(S), AUTHORIZED RE~TATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If tho ~ holder b an ADDITIONAL INSURED, the pollcy(l~) immt ho ondomed. If SUBROGATION 18 WAIVED, subject to the twn11~ and condltlon~ of the policy, cerlMn pollcis~ may require in andorsMnent. A tdatanlent on thie cMtfllCatd does no~ ~ rlghte to the naWflcate homer In lieu of such andomenlerd~.). ~ co~rr*c~ Five Stet Coverage Corp LoVullo Asso¢lMss, Inc.,u-~O~E.~ ;.,~. (631) ~7-6929 I ~ .,~ (631) 2t8-34tl 6450 TmnlIf Road m~umm *~ SCOTTSDALE INSURANCE COMPANY 4'1297 On-Lille Securify Ltd o~ Long Island ~NSU~ C: COVERAGES CERTIFICATE NUMIM:R: REVISION HI IMI~C:~: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY RE~JIREMENT. TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO V~rflCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUClES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. MMITS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS. $ A __ UMmELL~U~ ~J occur XB~Q009349 06~03~20t0 B6/03/20t'1 E,ACHOC, CU~ENCE Certificate holder Is named na eddl$onal Insured na required by written contract. Town Of South(Md Highway Depawnent Peconic Line Peconlc, NY 1t9M © 1988-2010 ACORD CORPORATION. Al rights reserved. ACORD 25 (2010/05) The ACORD name and logo am registered marks of ACORD AGENCY CUSTOMER ID: 964670 LOC #: Five Star Coverage Coq~ below) ADDITIONAL REMARKS SCHEDULE On-I.Ine Security Ltd of Long bland PO Box 132 MedforcI, NY 11763 (see below) Page 2 of 2 A: ~mJal~ Insurance Company A: ~co~dale Insurance Company 41297 CPS1222582 06/03N010 41297 XBS0009349 06/03/2010 06/~3/2011 This Section Intentionally Left Blank ACORD 101 (200~01) © 2008 ACORD CORPORATION. All dghts re~ervecl. The ACORD name and logo am m~ ma~ of ACORD