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HomeMy WebLinkAbout810 Greenfields LnTown Of Southold P.O Box 1179 Southold, NY 11971 Date: 08/13/09 Transaction(s): 1 1 Permits * * * RECEIPT * * * Receipt: 57364 Reference Subtotal 634 $181.50 Check~: 2473 Total Paid: $181.50 Name: R & R, Construction 282 Line Rd Manorville, NY 11949 Clerk ID: LINDAC Internal ID: 634 RECEIVED TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconlc Lane Peconlc: New York 11958: (631) 765- 3!q0 APPLICATION/PERMIT FOR HIGHWAY, EXCAVATION AND REPAIR 2009 APPLICATION IS HEREBY' made to the Superintendent of Highways of the Town of' Southold for the issuance ef an Excavation Permit pursuant to Chapter 83 of the Cede of the Town of Southold, Suffolk County, New York, and other applicable laws, ordinances or regulatlofls for the excavation herein described. The applicant agrees to.comply with all applicable laws, ordinances, codes and regulaUons, and to permit authorized inspectors to' mlake~ neceSSary inspections of the job site. Print or Type of Applicant Address I ~ c~ ~ 2) Name of Owner of Premises Address De~ciiPLion ano Leeatlo~l (Street Numbet-, Hamlet, Cross Street) (a) Is construcUon located wlthih 75 feet of tidal wetlands? *Yes *If yes, other Town permits may be required. Builder's License No. Plumber's License No. Electrician's License No. Other Traders License No. No Signpture of AppliCant / ! Date 5) a) Attach plot plan showing IoceUon of,,Prol§osed excavation and relationship to adjoining premises or public'streets or areas, a~d giving a detailed descrip~ tion 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 of a Highway Excevatioh Permit by the Town Clerk· 6) Tax Map: Section , Block , Lot 7) Starting Date: Completion Date 8) Work Schedule: phase Completion Date Excavation ...................................... Facility Installation ................... Backfill & Compaction ........................... Pavement Replacement .......... 9) Under which authority is the application made:._ 10)' Estimated Cost of Proposed Work: $.. /,, b'-/'~-), CiO 0-39 Page 1 of 3 12) ~3) Insurance Coverage: (Attach copy) b) Policy # c) State whether policy of certification on file with the Highway Depart- merit: d) Security: b) Fees for Al. A2. Coverage required extended to the Town: Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage. Surety Bond or Certified Check provided inthe total amount of $ Maintenance Bond provided: 2 years or .,. 3 years applications and permlt~'? Basic Application Fe~ ....... ~ "~/'0. /Service Connections excavations ~1 $20.00 = ~. N~. /Additional Excavations same service ~ $I0.00 = ~. B. Excavations 18'" in depth or leas: 0-100 I.f. = $10.00: · ~ IS I.f. e $0.10 - $ Additional C. Excavations 18" in depth to 5° in depth: 0-100 I.f.. = $30.00 I,f. ~ $0.30; Additional Excavations 5~ In depth and over: 0-~oo ~.f.. = I.f. ~ ~0.s0 = ~ .... Additional Fe No, Utility Repair Excavations 95~!0.00 = ~.. Repairs same service ~ $5,00 = $ Additional ... 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. SUPERI~LT.F~NDENT OF HIGHWAYS TOWj~ ~OLD~ YORK ' R~eiv~ by the Town Clerk '~ Date Permit No. ~ote: Pemlt ~plres one (1) y~r f~ Date of Iss~n~. No work to s~ wither ~8 h~r' notice to the Superintendent of Highways. Permit must be available for insp~tion. D-39 Page 2 of 3 A'CORD. CERTIFICATE OF LIABILITY INSURANCE OF,D = DATE.,DD ,R~co-x o8/o5/o9 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ~ INSORANC~ GROW ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE t~LVI?,T.~ OFFICE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 145 P~I,~ ~O, S~ LL 100 S. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MELVIT,T.'~ ~ 11747 Phone: 631-777-3131 Fax: 516-437-0435 INSURERS AFFORDING COVERAGE N~C # R&R Construction Enterprises 282 Line Rd INSURER D: ~o~ille N~ 11949 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 I CLAIMSMADE [] OCCUR MEDEXP(Anyonepe~on) $ ~ OCCUR [] CLAIMS MADE AGGREGATE $ $ WORKERS COMPENSATION AND I TORY LIMITS I Z lOETI~' A 12 WEC FX6968 10/01/08 10/01/09 EL RAOHACCIDENT S 1000000 SPEC~L PROVISIONS ~1~ E.L. D~SEASE - POLICY LIMIT $1000000 CER~FICATE HOLDER CANCELLATION Town of Southold Peconic Lane Peconic N~ 11958 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER ~LL ENDEAVOR TO MAIL 30 DAYS WRITr EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. / AUTHOR[~ED REPR A ' ACORD 25 (2001108) © ACORD CORPORATION 1988