HomeMy WebLinkAbout26342 Route 25ELIZABETH A, NEVILLE, RMC, CMC
TOWN CLERK
REC()RI)~ MANA(;EMENT()FFiCER
FRI,;EI)OM ()F [NFORMATI()N OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
,%¢mtho[d. New York 11971
Fax 16,311 765-6[45
Tu]ephone t631 I 765-lRO0
SOU tholdtown, north fi~rk, net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
August 25, 2009
'~' .
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/26/08
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt'8: 14415
Reference Subtotal
546 $180.00
Check~: 11872
Total Paid: $180.00
Name:
Middletown, Sprinkler Co Inc
326 Hwy 36
Port Monmough, NJ 07758-1333
Clerk ID: LINDAC Internal ID: 546
ELIZABI~TH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
FAX TRANSMITTAL
To:
From:
Dated:
Re:
Rob
Middletown Sprinkler Co
Linda J. Cooper, Deputy Town Clerk
March 27, 2008
Highway Excavation Permit
Number of Pages (including cover): 5
If total transmittal is not received, please call 631-765-1800, Ext 210
COMMENTS:
Penn,,' No -
TOWN OF SOUTHOLD
HIGHWAY DEPARTMElxrr
P.O. Box
Pe~onic, :New York 11958
(631)765-3140
$o ;LcI T .a': ,Ckrlt
_Ap. pLYCATION I P~ ~R ~GHW~Y ~CAVA~ON ~D ~
for ~c ~e of~ EX~~°R Pc~t
y . ~- o--~t of ~h~ of ~c To~ of Sou~olt~r app~b~ ~ o~S ot
~at~ f~ ~ e~~ ~ d~Cn~ ~ appli~t a~S to co~ly ~th all a~h~b~ Igc, oid~ncc~ cod~ aM
re~fi~ ~ m ~t authod~d i~m~ ~ n~c ~ece~ il~p~cUo~s of th~ job sRe,
prio~ or Tv~c
.... ~lican£
N*~e ofO~ of~
4. Ntfilder'~ l.~seNot
--~ e~cava6on ~d ~cl~o~p ~o adjoining p~cs or pubic s~ or ar~, ~d
Al~ pl~ pl~ ~g lO.On ofpm~u
5_ (a) ~g a ~ ~fion of layout ofox~tion-
At.ch aR o~ n~ ~
~) co~ befozc
W~k cov~ bl ~ a~fi~gon ~Y not
6_ T~x Map No.: S~c6ou ~0~ _
7. gm.lng ~e: ~/~/0 ~ ~Iedon Date:
Facility ~lsllation
pa~t R~lac~t
10. Esti~tcd ~s1 of Pr~ Work: S ~l ~ .....
D-39
t~/'A Lg:TT nR3. 800~/LT/TO
tOO/gO0~
(a) Ihsurance Company:
(¢) State ~ ~Cy ofcerlifi~on on file ~h [hg ~igh~y Dcpa~men~ ~
(~ Cove~ge ~ed ~t~d~ to ~c To~m
~ly ~ju~ ~ P~ ~ge: i3~,~ / S5~,0~ Bodily ~jm'y, a~ $50.000 prape~
13. S~ty: provid~ m ~e total Amo~
(a) Sm'e~ Bond __ or C~ified ~cck ~
(b) Ma~teum~ Bond pr~d~: ~ 2 y~rs ur 3
14. l;e~ fox App~fio~ ~d
No.
Addmopal
~ $150.00
Al. /~c~'icc C~yonectious cxcavaliOzl~ ~ $20-~
/ Add~o~l ~cavafl~ sa~ ~cc ~ S 10.~
No.
B, ~ca~fio~ 18" ~ d~ o~ 1~
0-100 i.[ = $10.~; Additional Lf. (~ S0_10 $ ....
C. ~mtio~ I R" ~ ~ to 5' M ~
0-I~ i.f = $30.~; A~ifional i-f- ~ $0.30
D. ~va~ons 5' in depfl~ and
~ 100 i.[ = $50.~; Ad~fional i.fi ~ $0.50 $
E. Utility Repa~ Exc&~tio~ ~ 510.~ $
~pni~ sang service (~
Notice to public utilities proolr ~t be pwvi~ ~d aflached ~ ~s a~h~hon pdor to ~su~ce
ofpc~L
Au~or~fion ~ ~eby ~mnmd to ~ To~I Cl~k of ~e To~ of ~ld W i~ a Highly ~x~vafi~ ~t ~;
in accurd~e ~ ~ a~tion-
Date Rcceiwd by thc Town Clerk
Da,c Permit Issued ~/a~ 6'/
NOTE:
D-39
Pe. mfit expires om: (1) 7ear flora dale of issuance.
Mo work to stazl with0t~t ~.8 hour notice to Stql6rinle. nd~n! of Highways.
2 of 3
X',/~ Ag:TI RIIJ. gOOg/£T/lO
~00/C00~
Z" l~v_ Co,o~~
.Copy Distribution:
Highway Department
,Engineer (with page 3)
Applicant
Town Clerk (Origil~aI)
1${
2"0
4~h
Inspection Date
INSFECTOR'S RECORDS
Findings (use code)
REMARK~
Applicant Notified
(To P~,mit Clerk)
C~ODE
lB Improper Barricades
IL Improper Lights
SI' S'anken Tre~h or Excavalion
UTM Unable to Mca~um (duc to backfilling)
BUC Building Under ComlrucliOll
WIP Work In ~'ogress
DI':~ In.roper Backfill (too high, no~ sufficient)
I.IF,S lnspecto,' Holding for Fins1 Settlement o£Excavafion
KFR Ready tbr Kcpair
D-39
3 of 3
~00/~00~ D't ti:II fllK e00$/gl/10
ACORD. 'CERTIFICATE OF LIABILITY INSURANCE O.,D
~-~
l,L%ddlel~wn Sp=inkle= Co ~nc
~d ~ ~on
326 ~ ~36 I~RD
~AGES
~. X CO%tlvlEF~IAL C~[NE~AL L[,a~[L[TY 8'14'7'12'70 04/07/0'7 04/0'7/08 pRE:M~sEsUY~W~r~ "J h't:r~'CU(Ea OCCt.I~Y:m®) $ 100 ,000
[~d~t'Z Zn~u~ed ~ c~mm, cLu,~mo~,~w'z~ 04/0'7/0'7 04/0'7/08 ~N~&~W~Y $1,000,000
~ ~ ~A~O S[4~1270 04/0~/0~ 04/0?/08
A [ ~dt'l ~nsu:ed b~ ~ ~T35 04/0T/0~ 04/0~/08
A ~c~ ~ c~,Ms~ SL4~1270 04/07/0~ 04/07/08 AG~EGA~ $ 3;000,000
CERTIFICATE HOLDER CANCELLATION
SOUTHO'r,
Town o£ 8ou'chold
High~ay Department
PO Box 178
Pe~onic N~ 11958
ACORD 25 (200t/09)
01/24/08 12:13 PM , ~astern Locating Service, Inc.
To: MIDDLETOWN SPRINKLER CX)MPANY
Attn: 'JUDY DOBSON
Voice: 732-787-1700
Fax: 732-787-8946
Re: Locating facilities in the a~ea of your excavation
01/01
This is an important Safety Message from .
We are replying to your request to locate our underground facilities
in an area where you are planning excavation work.
The following is the current status of our facility mark/ng in the
area specified in your notification.
Ticket number 80230639 at the following location is:
: The informationyouprovidedfromthe one call center Keyspan and
L.I.P.A. facilities are marked and potentially in conflict with
your excavation described on the one call center ticket. Re~e~mber
to use caution when digging near or around facilities, for LIL.
County: S~m~LK
Place : (~3T~HOGUE
Street: MOORES LN
Ticket number 80230643 at the following location is:
: The information you prOVided from the one call center Keys]man and
L.I.P.A. facilities are marked and potentially in conflict with
y~ur excavation described on the one call center ticket. Remember
to use ~aution when digging near or around facilities, for LIL.
County: SU~LK
Place : C~JT~HOGUE
Street: MOOR, S LN
Please call 631-567-7800 if you have any questions.