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Home My WebLink About800 Crown Land LnTown of Southold P.O Box 1179 Southold, NY 11971 Date: 03/31/11 * * * RECEIPT * * * Receipt#: 99848 Transaction(s): 1 1 Permits Reference Subtotal 692 $150.00 Check~: 711 Total Paid: $150.00 Name: On-line, Securi~ Ltd P OBox 132 Medrol, NY 11763 Clerk ID: LINDAC Internal ID: 692 Permit No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Pcconic Lane Peconic, New York 11958 (63 I)765-3140 APPLICATION / PERMIT FOR HIGHWAY F. YC&VATION AND REPAII~ APPLICATION IS HERliBY made to the ' ' pumuant to Chapter 83 of tl~ Code of thc Sup~mtendent of Highways of tho Town of Southold for the issuance of an Excavation Perm/t Town of Southold, Suffolk County, New York, and other applicable Iowa, ordinances or regulations for the excavation herein described. The applicant agrees to comply with all applicable laws, ordinances, codez and regulations, and to permit authorized inSPectors to make n~cessary inmpecfions of the job site. Name of Applicant Name of Owne~ of ~,ex~es Work D~iplion and Location (Street Number, Hamlet, Crozs Stme0 (a) Is construction located within 75 f~t of tidal wetlands? *If yes, other Town permits may be required. 4. Builder's License No. E!ectrician's License No. Address of Applicant Address of Owner * Yes. No / Plumber's License No. Other Trade's Ljcanse No. / Date 5. (a) Attached plot plan showing location of proposed excavation mad relation~hlp to adjoining premises or public street or areas, and giving a dets/led description of layout of cxcavation. (b) Attach all other necessar~ permits and lic, e~scs for this project (c) Work covered by tfiis application may not commence before issuance of a Highway Excavation Permit bythe Town Clerk 6. Tax Map No.: Section , Block ,Ph, ase Excavation Facili~ Imtallet/on Backfill & Completion Pavement Replacement , Lot Completion Date: ~/~r/~r 7. Starting Date: 8. Work Schedule: 9, Under which authority is application being made: I0. P~tlmated Cost of Proposed Work: $ ~ 11. Renoarks: Completion Date D-39 1 of 3 12. Imurance Coverage: (At~ach Copy) ~ · (c) S~ w~ po~cy of cc~fica~un on ~e wi~ ~ Highway Dep~nr ~ (d) Cov~ge ~q~ed e~e~ m ~e To~: / Bodily inj~ ~ pm~ ~ge: $3~,~0 / $500,0~ B~ly ~j~, ~ $50,~0 pm~ ~ge. 13. ~: (a) S~ Bond ar ~ ~eck (b) Maintenance Bond provided: 14. Fees for Applicatiom and permits: 2 years ar Basic Application Fee Al. A2. B. NO. NO. Bxcavaton~ 18" in depth or less 0-100 i.f. = $10.00; Additional Excavations 18" in depth to 5' in depth 0-100 i.f. ~ $30.00; Additional Excavations 5' in depth and over 0-100 i,f. --- $50.00; Additional NO. AddifionaI __/Service Connections excavations ~ $20.00 __/Additional Excavations same sexvice (~ $10.00 i.f. @ $0.I0 i.f. @ $0.30 i.f. ~ $0.50 Utility Repair Excavatiom @ $10.00 Repairs same service ~ $$.00 provided in the total Amount orS 3 years. $ $ $ $ $ $ $ TOTALS f~'~ · Nolice to public utilities proof must be provided and attached to this application prior to isau~ce of permit. Authorization is hereby g~anted to the Tovn~ Clerk of the Town of Southold W ism~ a Highway Excavation permit to: Date Received by the Town Clerk Dato Perm/t hsued in accordance w/th this application. SUPERIN't E~DANT OF I-~GHWAYS TO SO .O NOTE: Permit expires one (1) year from date of issuance. No work to stur~ without 48 hour notice to Supcfintedant of Highways. Permit rrmst be available for inspection. D-39 2 of 3 Copy Distribution: Highway l parUn nt Engineer (with page 3) Applicant Town Clerk (Original) ]st 3~ Inspection Date INSPECTOR'S RECORDS Findings (use code) REMARKS Applicant Notified (To Permit Clerk) CODE lB Improper Barricades tL Improper Light~ ST Sunken Trench o~r Excavation UTM Unable to Measure (due to bacl~illing) BUC Building Under Const~xwtion WIP Work In Progress DB Inpropor Baekf'fll (too high, not sufficient) I':iFS Impeetor Holding for Final Settlement of Excavatrion RFR Ready for Repair D-39 3 of 3 CERTIFICATE OF UABIUTY INSURANCE o.,2°. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER~ NO RIGHT~ UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOE~ NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND O~ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 11'11S CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEl%YEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER~ AND THE CERTIFICATE HOLDER. iM~RYANT: If the corb'floa~ holder is an A~K)NAL INSURED, the pollcy(l~) moat be endorsed. If SUBROGATION IS WAIVED, subject to the tmm~ and condlt~ms of the policy, certain pellcis~ may require an endor~mont. A sttd~ment on this coriffloa~ does nof ~ r;~h~ to the certlflcatd holder in lieu of such endor~nmof(s). ~Om~CE~ CO~TACr .~um, FIv® Star Corm'age Corp LoVullo A~>clatne, inc. ,u~O'E~,. =,.~. (631) 567-5929 I ~L~~ ~t, (631) 218'3411 6450 Tranelt Road E-~WL Depew, NY 14043 ]p=,,=== ~; SCOTTSDALE INSURANCE COMPANY 41297 INSURED IN~URER B: On-Line Security Ltd of Long I~land wsu~ c PO Box 132 Meoford, NY t COVERAGIF~; CERTIFICATE MI THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOV~ FOR THE POLICY PERIOD INDICATED. NOT~Mll'ISTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT ~ITH 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. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS. A ~GE~E~N.L~EILrn, X CPSt222682 06/03/2010 06/0~/20tl EACH OCCURRENCE $ 1,000,0~ ~_~ occu~ XB80009349 06/03/2010 i06/03/2011 EACHOCCUm~NCE ~ 5,000,00~ CerUfloate holder is oamed as additional insured as required by written contract. Town Of Southold Highway Depmt~rmnt Peconlc Lane Peconlc, NY 11958 AGENCY CUSTOMER ID: 964670 LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Five Star Coverage Corp (see below) see below) On-Line Security Ltd of Long Island PO Box 132 Medford, NY 11763 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25(2010/05) FORM TITLE: Certificate of Liability Insurance Carder Name NAIC # Policy # Policy Eft Policy Exp A: Scoftadale Insurance Company A: Scoftsdais Insurance Company 41297 CPS1222582 41297 XBS0009349 06/03/2010 06/03/2011 06/03/2010 06~03/2011 This Section Intentionally Left Blank 31/03 '11 'rltU 13:55 FAX 631 765 6145 SOIYI'IIOLI) TOWN CLERK ~001 *** TX REPORT TRANSMISSION OK TX/RX NO CONNECTION TEL CONNECTION ID ST. TIME USAGE T PGS. SENT RESULT 1544 31/03 13:53 01'44 4 OK 6548208 ?ermit No. TOtArN OF SOUTHOLD HIGHWAY DEPARTMLrNT Peconic Lan~ Pe~.onic, New York 1 I958 (631)765-3140 Work De~,iptloa a~l Location (Su'ect Number, Hsml~, Cro~ S~reet) (a) Is a~nslruc~ioa locaI~l ~,ith!n 75 f~et of tidal wefla~ls? .*If y~s, od~r To'a~ p,m~s maybe m. xluired. APPLICATION ! PERMIT FOR HIGID~Ay EXCAVATION AND S~,EPAm APPLICATION L~ HEREBY r~j~ ~o t1~ Superintendent of itigh'.~ay~ of the To~ of Sou~oM for ~ i~e of ~ Exca~on P~ p~u~t m C~p~ 83 of ~ C~ of ~ To~ of So~ol~ S~ ~, N~w Y~k, ~ o~r a~plicab~ ~w~, ~s or re~ous f~ ~ e~on ~ des~& ~ ~H~ ~s ~ ~o~ly w~ a~ a~able la~ ~d~-ces, c~ ~ ~o~, a~ to ~t aut~ ~cctom to ~ ~c~ ~o~ of ~e job ~. ~ o~ ~ ........... ~~ ........... N~ ofO~ of~ ~ 4. B~ld~r'$ lice. use A!o. £]~Iriciau's Licea~c No. * Yes No 5, (a) A?~chcd~t~an~h~wi~g~cat/~n~fpr~p~scdcaicava~nand~c~a~`~adj~;"~prt~r~s~~ giving a dciail~l description o~ layout o£~xcavation. Co) Attach all offer necessary permits and llc~mea for this projert (c) Work covered by this applicatio~ may not cotr,m~e berate issuance of a Flighway Bxcavalion P~uai by t~c Town Clerk. 6. Tax Map No.: Section , , Block , , Lot