HomeMy WebLinkAbout3245 Hortons LnTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/24/11
* * * RECEIPT * * *
Receipt#: 98130
Transaction(s):
1 1
Permits
Reference Subtotal
688 $180.00
Check,:1736
Total Paid: $180.00
Name:
American, Unde~round Utilitie~ Cablevision
P OBox 900
Eastpo~, NY 11941
Clerk ID: LINDAC Internal ID: 688
Permit ~o.~~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT.
Peconlc Lane
Peconlc: N.e~ York 1.19S$:
,APPLICA.T. IONIPERMIT FOR HIGHIfAY. EX~;AVAT. ION AND REP, A.I.R.
APPLICATION IS HEREBY' made to.the Su~erin~e~cle~t of Highways of t~e Town
of Southold for the i$~uance ef an Excav'atlol~ Per,it 'p~rsuant to Chapter 83 of the
Code of the* Town of Sm~thold, Suffolk Coullty, New yorkw and other appli~:~ble laws,
ordir~nces or r~3ulatlo~s ~or the e~eavatloh herein describe, The Iq~ll~t a~ree~
to u:~Ip~y witl~ ali applic~ble laws, ordinances, code~ and regdaUo~s0 and to permit '
atrthortz~:l Inspectors t~ e~ake~ ~ec~ry inspections of the job sit.~,
Print or Type
.Name of A~plicant AGG, ~ '
-- 14 me of Ow er of_p~m~_e~ ·
· If y~, ~h~ T~ p~l~ ~ ~ r~ulr~.
Build~s .Llce~ Ho. PI~ Li~se
El~id~s Li~se Ho. O~ T~d~s Li~
~te
5)' a) At~ plot pbn ~owl~ I~Q~ ~:~ ~ a~ ~atio~ip'to
~ln[n~ p~-~ publlc's~ or a~s, and gi~ng a da~ll~ d~cd~
tl~ of la~' of ~tlon.
b) A~& all ~r ~ ~tJ and ~ns~ for ~is 'pmj~t.
' c) - ~',~v~ by ~is appli~b my not ~e~ce ~ ~n~ of a
Highey ~n~ Pem~ ~ ~e Town
· &3 Tax Map: ~n , ~ ..., Lot
7) Sta~in~ Date: ~pletloh
~mple~o~ Date
~ntlo~ .........................................
Fa~ll~ lns~l~Uob .................................
~ac~ll' ~ C~p~tioo ......... , ....................
~ent Repla~ent ..............................
I01 Estlmat~ ~st of P~s~ Work: ~ , ,
D-39 Pag~ 1 of 3
Insurance Coverage= (Attach cc~y)
a} Insurance Campany:~(-Ol'~-& ~ ~- "
~Ve~ge r~uir~ ~t~d~ ~ ~e Tan:
~lly InJu~ and p~y ~mge: }~0~1~,660 B~Iy InJu~,
and $50,00~ p~
_m; terrifiC1 Check provided In'tho
total amount of $
~in~ ~ p~id~= '2 y~ ~ ,.. ~ Y~.
a~li~ aM ~ ~ ~n F~ ........ }~SO. O0
NO.
De
RepaJr~ sam servic6
Acldit~ona!"
~i~
mis 'appli~6 pH~
Authoriz&tlol~ Is hereby granted to Ute Tovm :lek of the Toe of S~uthdd to
Is.~ue a Highway ExcavatJo6 Permit 'to:
In'accordance with this 'applic;f~oh,
SUPERINTENDEItT OF HIGHWAYS
4/ 2,/
Received by the Town Clerk
Date
Permit 'No.
Permit expires one (1) year from Date of I~.~uancn,
No work to ~l:art wlttiout U hour' notl .c~ to the 5uperlnta~. t of Highm~ys-
Pemit 'nus~. be m~l~ble for
· Highwa~ De~ar-tment
In~c~ector
Applicant
2nd
IH SPE CT 0 R"*$
Insp~ Date
RECORD
Findings (u~ c~cle}
Applicant Notified
o rmit 'Clerk) . .
REMARKS
CODE
lB ': Improper' barricades
IL --Impl~oper Ik3flt~
ST - Sunl0e~ trench or ~.~avation
· UTM - Urmble to me~sure (dUe to ba~dd:illir~d)
BUC - Buildlr~ ur~ler Construct~
WIP - ~ in'pr~;Iress
DB -'lmprope~ backf~l'(t~o high) (not suffl .c~t) .
HFS -' Inspector heldln~l for ~ ~_-~_ k~mmt or ~.~a. v~.~.n
RFR - Reach~ to ~palr ·
Pago 3 of 3
From:aj bonocore 6312345920 02/22/2011 08:42 #048 P.002/002
CERTIFICATE OF LIABILITY INSURANCE o2/2=/2D 1
P~c)o~ce~ THiS CERTIR~TE I~ ~UED ~ A MAWR OF INFO~A~N
ONLY ~D CONFE~ ~ ~O~ UPON THE CER~FI~
A. ~. ~o~o~o~e ~ Z~. HOLDER. ~IS CER~FICA~ DOE~ NOT ~END, ~ND OR
~777-18 Ve~e=~ H~=~aZ ~tg~way ~TER ~E CO~E ~FORDED BY ~E POUCIES BEL~.
Z~Z~tm, ~ 11749
m631 325 1797 m~ m~u~ E:
COVERAGES
GENF. RAL Lla. B~LITY EAC¥10C~RENC~ $ 1 · 000. 000
~ ~C~GE~ ~{~ s 100,000
I~ ~occ~ ~m~.~) * 5.000
A ~ C~81312527 1/10/11 1/10/Z2 ~ ~m~ s 1,000.000
~ ~ c~ ~mEs ~; ~u~- ~A~ t 1. 000, 000
~ ~ (~.~i~) t 1,000,000
~ __ HI~D~T~ ~ ~0~0~8~ ~/~0/~1 ~/~0/~2 ~LYI~
~ ~ ~.~ ~ 2,000,000 i
I~UR ~ C~I~E A~TE I ~, 000.000 ~
~021351916 1/10/11 1/10/12
~ ~ s 1~000
~ ~~ ~ ~005-81-5576 6/16/10 6/16/11 ;.c.~ s 1.000,000
C ~m ;.~.~-~m~ s 1,000,000
~ ~v~ ~ e.L o~;. ~u~ c~ s 1,000,000
D DZB~Z~Z~ 5283378-001 1/1/11 12/31/11
The Certificate Holder is Additional Insured as their interest may appear.
CER~FICATE HOLDER CANCELLA~ON
Town of 8ou~hold
53095 Main Road
SouthoZd, NY 11971
ACORD 25(200W0'1 )
The ACORD name and logo am reg~red mmrlm of ACORD