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HomeMy WebLinkAbout205 Boisseau AveTown Of Southold P.O Box 1179 Southold, NY 11971 Date: 03/02/06 * * * RECEIPT * * * Receipt#: 2458 Transaction(s): 1 1 Permits Reference Subtotal 435 $150.00 Check#: 2458 Total Paid: $150.00 Name: North, East Communications 746 Montauk Highway Bayport, NY 11705 Clerk ID: LYNDAB Internal ID: 435 6~/03 '06 WED 13:66 FA]: 631 765 6145 ' * ' ' Perm--. SOLrI~OLD TOM CLERK TOWN OF SOUTHOLD HIGHWAY DEPARTMENT. Pe~onlc Lane Pecorllc: I~lew York 11956 .(631) **~ Hlghwa.~ ~] 001 APPLICAI~ION/PERMIT FOR HIGHWAY ExCAvATION AND REPAIR APPLICATION IS HEREBY· made to.the Superintendent of Highways of the Town of Southold for the Isguam:e of m~ Excavatioh Penalt 'p,u~nt to Chapter 83 of the Code of the' Town of Emuthold, Suffolk Couflty, New york, end other applif~ible laws, ordin~lces or r~ulaflofis for the e~ca~/atioh herein descril~d, The ~ppllc~nt agrees to comply wlt~ all applicable laws, ordlri~mces, code~ and regtdafio~s, and to permit * authoHz~:l Inspectors t~ mtake~ nec~ary in~.pectlons of tho job sit&. Print or Type · Name Of APplicant ' AddreSs ' ~amo of Ownor ot' Premi~s Work Des~iptio~ ar~ I~ce~ion {$~reat Number. Hamlet, Cros~ Street} Is mnstructie~ located withih·75 feet of tidal w~tlandst *Y~$._.___~o · If yes, other Town permlt~ may be requlrad. ~) 13uilder~s .License .No. Plumber~ Lic~lse Ho. Electridah's LiCe~sa No. Ot~r~adds License No, Date 9] 10) · 11) a) Attach plot plan showing Iocafi°n o~,p~ ex,cevatJon and relatioftship'tO adjoining premises.or public 'streets or areas, and giving a detailed descrip= t[o~ of layout' of excavation. , b) Attach all other necessary permit~ and licenses for this 'project. ' c) · Wb~l~.,~vered by this applicaUo~ may not commence before issuance of a High~ay ExsavaUo~ Permit by the Town Clerk, , 6) Tax Map.' Section 7) Starting Date: 8) Work Schedule: Phase · Block , Lot Completim~ Date . . . Completloh Date Excavatioh ......................................... Facility Installatloh ................................. BecK'fill' g Cmnpaction ......... , .................... Pavement Replacement .............................. Under' which authority Is the appllc~tioh made.' Estimated Cost eie Proposed Work: $ Remarks: D-39 Pag~ 1 of 3 ql/03 '06 WED 13:56 FA][ 631 765 6145 TOWN CLERK -*-,-, H18hw~T Dept ~]002 insurance Covera~/e: (Attach copy) a) insurance Company: b} Pdicy ~ c) State whether policy of certification on file' with the Highway Depart- d) Coverage required extended to the Town: Bodily Injury and property damage: ~300,000/$500,000 Bodily Injury, and SsO, OOO. property danmge. Security: e) Surety Bo~d e~ Certified Check provided In'the total amount of $ b) Maintenance B~nd provided: '2 years or .~ years. Fees for applicatiohs and permit~: Basic Application Fee_ ........ $150,00 Al. ISerYic~ Connectloh$ excavations 6 $20.00; $ A2. /Additional IExcavatio~s same service ~ $16.00 -- ~ Do Excavations 18" in depth.ur less: 0=100 I.f, = $1a. 00 ' I.f. · $0..10 - $ Additional ~vati~ I~' in d~ ~ ~ in d~h: Ad~l' Ex~vafl~s 5' in d~ ~d over: hr. e~.s0=~ ED Utility Repair Excavatiohs e$~O. oo ~ $ NO. .Repair~ same ~ice C ~.O0 = $ ~difioMI" Notic~ to public 'utilitie~ proof must be provided and attached to this 'applic~tloh prior to issuance of permit.' Authorizati°n Is hereby granted to the Tmvn Clerk of the Town of S~uth~d to IsSue a Highway Excavatlo~ Permit 'to: In'accordance with this 'applic~floh. Received by the Town Clerk ~31~ IO(_~ Date t Dante Note: Permit expires Dna {1) y~r f~m Date of [ss~n~, ' - No work to s~ Wight ~ ~f noti~ ~ the Superlnt~t of Highways. Pem~ 'must be available for D-39 Page 2 ~ 3 Omni R;6k ~anagement, Znc. ONLYAND CONFERS NO RIGHT~ UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 308 Nest Nain St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 100 S~J thrown, NY 11787 INSURERS AFFORDING COVERAGE NAJC # ;NSU~O North East Cmmmnications Contracting ];T Tnt. INSURERA: Great American E & S Zns. Co. 746 Nontauk Highway ~u~a: Utica Mutua] Zns. Co. Bayport, NY 11705 r~sue~c: State Insurance Fund ~SUR~O: First Rehabilitation ]:ns. Co. iNSUR~e ATG Member Companies COVERAGES THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO'I'WlTHSTANDING 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 UMrFS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. o~sa~.ua~u~ GL05850024 03/24/2005 03/24/2006 E~CHOCCUP~-NC~ IS 1,000,00( X COMM~C~LC~NER~L~mUTY O~£TOR~rmDI $ 50~00( A P~J~.~L & ADV INJURY S 1,000,00( C-a'CERAC AOC, R~OAT~ $ 2,0OO,00( GEN~ AGGREGATE UMIT APPLES PE~ PROOUCTS - COMP,'OP AGG S 1~0OO, 00( AUm~O~CSua~ur~ BAC3284475 03/24/2005 03/24/2006 COMBINE. D SINGLE LIMIT 1,000,00C B -~- H~E~ AUTOS SOreLY ~JURY ~xc~s~amu~u~mu~ EBU9024756 08/24/2005 03/24/2006 ~OCCURRENCE $ 3,000,000 X~ occu. [] CL~,MS U~ ^C~C~C~'rE $ 3,000,000 E $ ~n'EN'nON s 10,00ii s WOm~SCO~ONX,~ ]:13558739 03/24/2005 03/24/2006 X ]~n~¥Hu~l I°~' ~PCO~u~s~Y ORDERED FRON SZF E.LF-~CHACC~-~T $ 1,000,000 ~ ~Disability Policy DBL1191321 09/02/1998 Continuous D · e following are included as additional insured as required by wPitten contract and persuant to the :erms and conditions of stated policies with ~espect to the general liability coverage: See attached ............. CERTIFICATE HOLDER CSC Holdings, ]:nc. & the entities listed as additional insured 1111 Stewart Avenue Bethpage, NY 11714-3581 CANCELI.ATIQN Robert Mast rantonio ~CORD 25 (2001108) FAX: (631)472-2335 ©ACORD CORPORATION 1988