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Home My WebLink About1490 Duck Pond RdTown of Southold P.O Box 1179 Southold, NY 11971 Date: 10/28/09 * * * RECEIPT * * * ReceiptS: 60997 Transaction(s): 1 1 Permits Reference Subtotal 640 $15500 Check~: 1401 Total Paid: $155.00 Name: American, Underground Utilities/Cablevision P O Box 900 Eastport, NY 11941 Clerk ID: LINDAC Internal ID: 640 TOWN OF SOUTHOLD HIGHWAY DEPARTMENT P.O. Box 178 Peconic, New York 11958 {631)765-3140 RECEIVED OCT 2 8 2009 Southold Town_Clerk APPLICATION / PERMIT FOR HIGHWAY EXCAVATION AND REPAIR APPLICATION IS HEILEBY made to the Superintendent of Highways of the Town of Southold for the 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 Type Name of Aoolicant ~ t fi0 V/! q?'4 / Address of Applicant 2. Name of Owner of Premises Address of Owner Work DeScription and Location (Street Number, Hamlet, Cross Street) (a) Is construction located within 75 feet of tidal wetlands? * Yes · If yes, other Town permits may be required. No 4. Builder's License No. Plumber's License No. Electrician's License No. Other Trade's License No. Sign'~ e~of Applican Date (a) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public street or areas, and giving a detailed description of layout of excavation. (b) Attach all other necessary permits and licenses for this project. (c) Work covered by this application may not commence before issuance ora Highway Excavation Permit by the Town Clerk. i0. Estimated Cost of Proposed Work: Tax Map No.: Section , Block Starting Date: [/L..~"~ ,.~ ~0/~ Work Schedule: Phase Excavation Facility Installation Backfill & Completion Pavement Replacement Under which authority is app ication being made: _/f/,~ ~ g. '~' V/,-~ , 10OO -- , Lot Completion Date: Completion Date D-39 1 of 3 12. Insurance Coverage: (Ailach Copy) (a) Insurance Company: __ _.~( m'-7'"7'~::~t~- ..r~ .La ~'~ (b) mollcy#:~/ ~ /.~'~- O 7/~--~ (c) State whether policy of certification on file with the tlighway Department: (d) Coverage required extended to the Tow, r: Bodily injury and property damage: $300,000 / $500,000 Bodily Injury, and $50,000 property da~nage. I3. Security: (a) Surety Bond (b) Maintenance Bond provided: or Certified Check 2 years or provided in the total Amount of $ 3 years. 14. Fees for Applications and permits: Basic Application Fee $ 50.00 Ig-..U Al. A2. B. /Service Connections excavations ~ $20.00 No. / Additional Excavations same service @ $10.00 No. Excavations 18" in depth or less 0-100 i.f. = $10.00; Additional i.f. ~ $0.I0 Excavations 18" in depth to 5' in depth 0400 i.f. = $30.00; Additional i.f. ~ $0.30 Excavations 5' in depth and over 0-100 i.f. = $50.00; Additional i.f. @ $0.50 No. Additional Utility Repair Excavations ~ $10.00 Repairs same service @ $5.00 TOTALS 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. Date Received by the Town Clerk ,/~;)/~J~//~ ~ Date Pernut Issued J~/~/~/7 Permit No. NOTE: Permit expires one (1) year from date of issuance. SUPERINTENDENT OF HIGHWAYS TOWN Of.~80~I'HOLD, NEW YORK No ~vork to start withont 48 hour notice to Superintendent of Highways. Permit must be available for inspection. D-39 2 of 3 Copy Distribution: Highway Departmcnt Engineer (with page 3) Applicant Town Clerk (Original) 3rd 4th Inspection Date INSPECTOR'S RECORDS Findings (use code) REMARKS Applicant Notified (To Permit Clerk) CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure (due to backfilling) BUC Building Under Construction WIP Work In Progress Improper Backfill (too high, not sufficient) HFS Inspector Holding for Final Setilement of Excavation RFR Ready for Repair D-39 3 of 3 89/22/2889 11:42 16312345928 AJ BONOCORE AGENCY PAGE 82 *,ACO~D,. CERTIFICATE OF LIABILITY INSURANCE o9/2=/2o~:~ p~ODUC~R THIS CERTIFICATE~ IS ISSUED ~ A MATTER OF INFORMAI~ON ONLY AND CONFERS NO RIGHTS UPON THE CER3iFICATE A. ~. BOnOCOZ~ Agency ThC. HOLDER, THIS CER~FICA~ DO~ NOT ~END, ~ND OR 1777-18 ~ete~; M~i~l ~ig~7 ~R ~E CO~E ~ORDED BY ~E POLICIES BELOW. P.O. ~x 900 ~c: ~Q ... ~63~325 1797 Dh f~ ~ COVERAGE8 MAY PERTAIN, THE IN~U~NCE AFFO~ED ~Y THE ~ICIES DESCRIBED HEREIN IS SU~ECT TO ALL THE TER~, EXCL~N8 AND CONDITIONS OF SUCH Z ~RC~em~LI~ m~s~ S [00, 000 [c~ ~u. ~(~.~} s,,. ~,000 ~ ~ t 2,000,0~ ........ ~~ ~ oc~ s 2~00~ 000 ~. ~,~D~ A~ s 2~000.000 ~U083330137 1/10/09 1/10/10 ~N S 10.00q ~m WC 007-45-5201 6/16/09 6/16/10 ~,u~Am~ s 1~_000,00~' ~000~900 D DZ~ILI~ 5283378-001 01/06/06 ~til c~cel The CertiEica~e Holder i~ ~d~tional Insured as their interest ~y ~ppear. CERTIFICATE HOLDER Town of Southol~ 53095 Main Road Southold, NY 11971 CANCELLATION · )ACORD CORPORATION 1988 ACORD 25~20Sl/08) 09/Z2/2009 11:42 16312345928 AJ BONOCORE AGENCY PAGE 81 To: TO~I of Sc~thold From.. Marion Bonocore F~)~ 765-1750 Page~ 2 Phone-. 76~1801 D~e; B/22/09 Amel~ Underground Inc. Ceff~l~ of Insurance · C~nments: Attached please find the Certificate of Insurance that you requested for our insurBd~ American Underground Inc. If you h~ve any que~Uons or require ecldl~mlill ;nformltiolt do not heoitmte to contact our Th~nk you for your ~ntion to this matter.