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Home My WebLink About60 Great Peconic Bay Blvd * * * RECEIPT * * * Date: 06/02/14 Receipt#: 171120 Quantity Transactions Reference Subtotal 1 Excavation Permits 935 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#5031 $170.00 Rossano, Berti Construction Inc Name: Rossano, Berti Construction Inc P0Box 1103 Wainscott, NY 11975 Clerk ID: LINDAC Internal ID: 935 0002/005 05/12/2014 Mom 12, 30 FAX Ponni\ No. _ rl~^ TUWNUF80OTB0LD ~ \ ~ HIGHWAY DFPAR,[mENT Pezmmiclanc , [u �o � Pconuiu,Y4cvv York 11958 Vk (6-)1)705--)140 APp\ I[AT)0N |8H[K[8YmodctothcSuprrio,rndro/u[High%kxyso[\kcTonoo[Soo[hu|dhorthcissoxnceo[xo6xcovmk`uPcnnit puao-'nt to Chapter 237 ofthe Code oftheTown OfSouthOld, Suffolk County.New York,and other applicable laws, ordinances or rct-o|-ioosk`rthe excavation herein described, Theapplicayn a0rees to comptv%vith all applicable laws,ordinances,codes and 000| ioos.the oo "General oeceam! Inspections o[thcjob site. RECEIVED Print orTNJ)e \ 05sa*10'- \��-��_L�_ ----�1MJ—~� '--- Name o(App}imnt Ph � ��* �mnArr Address °"'` - _ � Z. ~� / /3 _____ Townrk_______ mamco/ Contmcw, Phone Number Address- --'r-- 3. ... ...��'��..... �� Name vf'PnpN Owner Requesting Service(i[opp|icahc) Address of Ownerion ai d Location Work Descripi 'S I lam let,C1 Yes No _ -Oss Street*if ves, otliel-vown permits may be required. �W� � Ahnrmuuon � mm gucxo ��m ~v, '—' NOTE,: All Application/Permit Form is Required for acomplete application! Date 5 (x) Attached plot plan to reasonably and adr4oum�doo � proposed � work. Provide accurate �osd�mu site plan xhowin&Lhc \ucxhonn[xUprupn�dexcavations and o|mionshiptn adjoiningp 'm\yos.poh|�ooermcvur�a.xnd8jvcodomU*dd*surp/kmof all site and pavement restoration work. (h) Attach all other necessary permits and licenses for this pnqicu. db T*� Clerk. (c) YYorkcovomdhyth� mm opp|ic �oomu?ncommencrbc0orcisauunocofoHi8h*xy2xouvmiuuPcnnkby theTown . u lax Mal) No.: District 1000 Section ' Blnnk 7. SuninuDxu: Completion Date: -__-._--____--- - 8. Work Schcdo|cCorul)le I tion Date Work Schedule �� ~ Excavation \.`L^ Facility Installation "^�= ~~r~`~^~~ ---�� f��oono�uru,�uwxu Buck0)6LCump}o\km Pavement Replacement _ Complete Application. V Under which authority iuapplication being made: __ in�modi�nd�Seelo*oCodrChxp^er2]7 (E)' Pnuvidc Rceo|u000by, nruodhwity 0nm.the Utility be / |0. [sti n1ated Cost o[Proposed Work: J | ! Kv marks: _L J� ' / | (�� ~~ fr �� /°-^`*x ` �`�«^«~-~` /-~ �� /=�--�`=+ � ' � I o� J |)'�4 � � � � os/zz/zozo MO -1-2--30m � ruo �� 00 03/005 |2. Ins omocrCoverage: (Attach Copy ) (x) }nso,mucCompany: (h) Policy - _................ _____� (c)State whether policy of*certification on 01u nith tIn Higim,ay Depmmew: (J)Co'onecrequired extended'othe Town: ------------------------------- AoyLox �dodio&Bodily injury, propcnycvcommercial hnJurycaused hyorattributable tothe work perhunncd: 01,000,000 per 0cconeouc and S 2.000.000 general o,, regxn. |l Sconi/ y: (o) SoroyBond orCcniUcdCheck provided hnthe total Amount o[$__________________. (h)Maintenance Bond provided: _ _2ycxnor ------_______ ] years. N. [ecs0or Applications and permits: 8u Sicaiion [c* S150.00 Al. �� er,icrConnections excavations $20.00 S No . A2. /Additional Excavations same service(,i�,$0.00 No. B, Excavations 18^ in depth or bo 0-100 |0.00; Additional L[ 6hso.\O $ ________________. C. Excavations 18^ indepth to5' in depth O'|OOLF. : $30.00; Additional $0.30 D. Excavations 51 iodepth and over 0'100LF. ~ S50.00; Additional LF.@$0j0 S _________________ E. ------ _ Utility KcpuirExcovotioos D10.08 No. Repairs same service @$5.00 $ Additional ��~~ TOTAL$ "^ |� Notice mpublic Utilities proo/muahoprovided and Shall 6eattached tothis application prior toissuance o[pcnxk. Authorization ishereby granted m/hcTo»oClerk o[thcToxoo[Southold missue xHighway Excavation permit to: ____ inuxcnn]uucc,,hh UhisnnpGcmion and subject tuthe Conditions"and"Special Conditions"o[ponnit(if vny)attached heroo. A YS — � W1. 0d�ndo ��--- _ ___--___- -__- _— Date Received hythe Town Clerk_ 6-02 — Il ^~^ Date Permit Issued / 0?, — /( Permit No. NOTE: Permit expires one(/)year Uomdate o[bam000. No work, 1nStart vithov|24 hour notice/o8opohmcndomot'Hiphwxyy. Permit most be ovoi}oh|c at all times |o,inspection, on site, during construction. D39 _ 2 o[ 3 �l(o)311 .�59Z /(he Ifb5saoo�°I 4,,e- Pka lot ce- -_ - _ epi ` zCo6,)6 of � MNI D � N i � �u 2014-05-30 11:29 R.BERTI CONSTRUCTIO 6313292498» P 1/2 ,4I °� WE OF LIABILITY IN �TEININ)0DIYYTT) SURANCE =8/2014 1FW CERTIFICATE IS ISSUED A8 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NOIDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BErffEN THE 193UING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT_ if 8M s at the holder Certain aApWTes ma INSURED. the Pollcy(fes)must be endgned. N$UBROG/1TiON IS WAIVED,subject to the eenns and conditions 4<the pokhen mme poIICIeE may require an endorsement• A statement on tn,$C"Wests does not confer dghts to the certMpab holds/In Ileo 0f such endon�smen s. PRODUCER CONTACT JAMES N,AGALS vvvvvv►►y►NN}}}}ppMpppE M PO BOX 777 .No.Eid) - EAST QUOGUE,NY 11942 sS. 611.255 44x4 / 11131-2110,4039(FAX) iNSURER(S)APFORDING COVERAGE NAiC• wsuaED INtiURER A FARM FAMILY CASUALTY INSURANCE CO INGURER e: R.BERTI CONSTRUCTION INC r PO BOX 1102 IRWRER C: WAINSCOTT,NY 11975 INSURER D 1�Su1t�q E. COVERAGES INSURER F. CERTIFICATE NUMBER: 101 893 REVISION NUMBER: ERTIFY THAT OF INSLIFIMTROMBELOW HAVE BEEN U D TO THE INSURED NAMED ABOVE FOR THE 10 10 INDICATED. NOTWITHSTANDING ANY RECUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHN;H 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 LIMITS SHOWN SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .._. AApppDLL��pp TYPE OF INSURANCE N6R I M1VP. POLICY NUMBQR KY! ��p� — A nEMEIIALLIAruTY i �I�.IMM76C/YYYY) LMTS X I COMMERCIAL OENERAILIABILITY 3101L9934 3/2/14 3/2/1"5 EACHOCCURRENCES _ 1,000,000 CLAIMS-MANI i OCCUR WREMA ENT G)_ 1 100,000 MEG EXP torr IstneA) � ._ 5.000 PERGONALtAOVINJLd:Y1s 1,000 Opp OiNY AGORECATE IF��MppIf..APPLIE6 PEROENERAL , � i A99REGATE 2,000,ow ---- POLICY SECT lOC PRODUCTS•COMP/Op ACG,-s 1.000,000 AYTOMI t I IAERJTY ASW AUTO ��yL I � - o SINGLE WAIT r AUTOS D A►�UTO6yy NED i BOOBY INJURY(iW PMon) S _. "MALI A070$ EO I WDDIIL�Y MUpR�Y jFW saxs")_S i I �cC1dwM GB U�ORELLA LIAR OCCUR FXCM LIAR ~EACH OCCURRENCE I S CLAIMS-MADE AGGREGATE OED �REf@NTtONS I YYORKlIIa OON►iMfAIiOM A S s i AND ENPLOYNENa LIAaN Iri 3152W8331 3/2/14 3/2/15 X i TO�Ry i MRs1 �°�'j ANY IPROPRIETORIPA��Da COTIYE Y f N''MIA .. j, p,T� Q.E.L.EACH ACCIDENT 1 100,0w ■1�[ap Oeoula Gx� I ' RIPTION Of OPERATIONS Dhow El.L DLSEA5E-EA EMPLOYEE,i 1 OO,wo DESLS .. E L d6Ea9E.P --- . i.. OUCY LIMIT 1 .0.1)00 � I I DESCRIPTION OF OPERAT&A I LOCATIONS I VENKUN(ANbch ACORD fill.AddlpOul Rd�I/Rf 8e1MAIdA.11 RIM 4 IpWnd) CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 275 PECONIC LANE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN PO BOX 178 ACCORDANCE WITH THE POUCY PROVISIONS. PECONIC'NY 11958 AYTHORQlO REIREMNTATIVE �( ®1965-2010 ACORD CORPORATION. AN rlphts swerved_ ACORD 25(2010/o6) The ACORD name and logo are registered marks of ACORD 2014-05-30 11:29 R.BERTI CONSTRUCTIO 6313292498» P 2/2 STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE In.Leal Name dt Address of Insured(Use street address only) Ib.Business'telephone Number of Insured R BERTI CONSTRUCTION INC PO BOX 1102 le.NYS Unemployment Insurance Employer WAINSCOTT, NY 11975 Registration Number of Insured Work Location of Insured(Only required if coverage isspeNfieally Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, ie., a Wrap-Up or Social Security Number Policy) 2.Name mud Address of the Entity Requesting Proof of 3a. Name of 1 nsurance Carrier Coverage(Entity Being Listed as the Certificate Holder) FARM FAMILY CASUALTY INS CO TOWN OF SOUTHOLD 3b,Policy Number of entity listed in box"is" 275 PECONIC LANE 3152W8331 PO BOX 178 PECONIC, NY 11958 3c. Policy effective period 3/2/14 to 3/2/15 3d. The Proprietor,PartntYs or Executive Officers are included. (Only check box It all partnen/ameerx Ineledtd) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box ILIA" fur workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)trust be listed under heat 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The insurance Carrieror its licensed agent will send this Certificate of Insurance to the entity listed above as the eeRiftcate holder in box"2". The lnsurance Carrier will also note the above certificate holder within/0 days/F a policy is caneelecidue to nonpayment of promdums or within 30 dqs lF there are reasons other than nonpayment of premiwns that cancel the policy or eliminate the insured franc the coverage indicated on this Gerl ytteate. (These notices may be sent by regular mail,) Otherwise,this Certificate Is valld for one year after thisfa nr is approved by the Insurance carrier or its licensed agent,or until the policy coradon dale listed in bar"3c",rAkkever is e Please Note: Upon the cancellation of the workers'compensation policy Indicated on this fora,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Insured has the coverage as depicted on this form. Approved by: JAMES N.AGALS (Prim marc of authorized representative yr licensed agent of insurance wrncr) i Approved by, N• S •1 (S�we) (Dak) Tido: ENT Telephone Number of authorized representative or licensed agent of insurance carrier: 631-288-4454 Please Note. Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to Issue it. C-105.2(9-07) www.wcb,ny.gov