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Home My WebLink About1205 Lake Dr * * * RECEIPT * * * Date: 05/23/14 Receipt#: 170107 4 Quantity Transactions Reference Subtotal 1 Excavation Permits 932 $160.00 Total Paid: $160.00 Notes: i Payment Type Amount Paid By f_ CK# $160.00 American, Underground Utilities/Cablevi f AMERICAN UNDERta UTILITIES CONSTRUCTION Bill Hague Construction Supervisor PO BOX goo Eastport N.Y.11941 (631)325-1797 PH/FAX (631)714-0369 CELL AMERICANUNDERGRD@AOL. LIKENED/INSURED i i i i i Name: American, Underground Utilities/Cablevision is P O Box 900 Eastport, NY 11941 f J r Clerk ID: LYNDAR Internal ID: 932 Pet njit No. TOWN OO HIGHWAY DEPARTMENT P.O. Box 178 Peconic, New York 11958 ► �^ (631)765-3140 ' APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY 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 Tyre 1. f M�/z �c'�ti/ �,rJ�� ✓Z�t�� (,�T�ur/6s PQ 4L,, � s`rPt>z; /1`7/// Name of Applicant Address of Applicant Name of Owner of Premises Address of Owner J /, 3- XVi�13L Work Description and Location(Street Number,Hamlet, Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. 4- Builder's License No. Plumber's License No. A144 Electrician's License No. /V df— Other Trade's License No. /Vr gnature of Applicant Date 5. (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 of a Highway Excavation Permit by,the Town Clerk. 6. Tax Map No.: Section 159 'Block S , Lot 7. Starting Date: 0-6 Completion Date:.�S�r v�2 2(,1 Lam/ / 8. Work Schedule: Phase Completion Date Excavation Facility Installation Backfill&Completion Pavement Replacement 9. Under which authority is application being made: /g(J v✓LAGTG2, FV---Z- 10. v-z �s4t3GEUiS/Oki oc 10. Estimated/Cost of Proposed Work: 11. Remarks: 0 A.;t -S�11-U C'7<V 4— fit/i L-L 1� �1/�`�G T/o,v`4�- ��✓L/L L/�/L� `/� �g�� D-39 1 of 3 12. Insurafte Coverage:(Attach Copy) (a) Insurance Company: (b) Policy#: (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extended to the Town: Bodily injury and property damage: $300,000/$500,000 Bodily Injury,and$50,000 property damage. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Applications and permits: _ Basic Application Fee $150.0 Al. /Service Connections excavations @$20.00 $ No. A2. /Additional Excavations same service @$10.00 $ No. B. Excavations 18" in depth or less 0-100 i.f. =$10.00;Additional i.f.@$0.10 C. Excavations 18" in depth to 5' in depth 0-100 i.f.=$30.00;Additional i.f.@$030 $ D. Excavations 5' in depth and over 0-100 i.f. =$50.00;Additional i.f.@$0.50 $ E. Utility Repair Excavations @$10.00 $ No. Repairs same service @$5.00 $ Additional TOTAL$ F. Notice to public utilities proof must be provided and attached to this application prior to issuance of permit. E#� 6 a * * * * * * * * * * * * * * * Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: fA`yNe- 'VQaA,, 0Y\ er 0vn'4 in accordance with this application. SUPERINTEN ENT OF IG A TOWN OF S UTHOL Y IhiCG'j M_ OKCAN4�10 rQ3- Date Date Received by the Town Clerk S o3 3 Date Permit IssuedJ�3I a() Permit No. q J a NOTE: Permit expires one(1)year from date of issuance. No work to start without 48 hour notice to Superintendent of Highways. Permit must be available for inspection. D-39 2 of 3 Copy Distribution: Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 15` 2nd 3rd 4 t (To Permit Clerk) REMARKS 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 DB Improper Backfill(too high, not sufficient) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 c O CQ _ I 40 k E N ! Zig + vz- W®RT ZZF tMo � � r � . ACORd DATE(MANDDh'YYY) CERTIFICATE OF LIABILITY INSURANCE 5/21/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the pol"Ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER GUNTACI NAME: A. J. Bonocore Agency Inc. PNHONE x 631-234-5595 AC.No431-234-5920 1777-18 Veterans Memorial Highway ADDRESS. I s 1 ands a NY 11749 INGURER(S) AFFORDING COVERAGE NAICM INSURER A TECHNOLOGY INSURANCE CO INSURED American Underground Utilities Inc. INSURERS cnartia/Mat'lnon Fire Ins Co of Fitts, FA P.O. BOX 9 0 INSURER C rt a omnerce asIndustry ns company Eastport, NY 11941 INSURER D Zur ch American Insurance Company ' INSURERE Hartford Life Insurance Co. INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INF;WCY EFF TSRR TYPE OF INSURANCE INeR V,yD POLICY NUMBER DNYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 rX+COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE X j OCCUR MED EXP(Any one person I $ 5 000 A r_ TPP1014207 ;5/30/135/30/14;PERSONAL t►ADV INJURY is 1,000,000 15/30/1415/30/151 GENERAL AGGREGATE $ 2,000,000 __GEN` is AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 1,OOO,OOO '. POLICY FK JEC ! LOC j $ AUTOMOBILE LIABILITY iSINGLE LIM I � 1,0 0 0,0 0 0 _ (Ea accident $ XI ANY AUTO BODILY INJURY(Per person) $ ALL OWNED I SCHEDULED TPP 1014 2 0 7— 5/30/13115/30/14 NON-OWNED BODILY INJURY(Per accident!$ A Auros '5/30/1415/30/15! $ NON-OWNED HIRED AUTOS AUTOS (Per acrid t $ X i UMBRELLA LIAB X ;OCCUR EACH OCCURRENCE s 5,000,000 --I iBE 015820104 j5/30/135/30/14 $ EXCESS LIAR CLAIMS-MADEAGGREGATE $ 5,000,000 DED 1 X 1 RETENTION$10,000 5/30/145/30/151 s WORKERS COMPENSATIONX WRV LIMIT IOTH ER AND EMPLOYERS'LIABILITY YIN _ ANY PROPRIETORIPARTNEfVEXECUTIVE '::6/16/1316/16/141 E.L.EACH ACCIDENT s 1,000,000 C (Y�ndtlory ie NH) EXCLUDED' NIA WC 005-81-5576 !6/16/1416/16/15!E.L.DISEASE-EA EMPLOYE$ 1,000,000 K s,descnbe under i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1, 000,000 D DISABILITY 5283378-001 01/01/13 112/31/13 ' E DISABILITY iLNY814925001 :01/01/14;12/31/14 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule.if more space is required) Project: Cablevision Repair. 'The Certificate Holder is Additional Insured as their interest may appear. i CERTIFICATE HOLDER CANCELLATIO Town Of Southold SHOULD NY OF THE ABOVE DE CRIBED POLICIES BE CANCELLED BEFORE P.O. BOX 1179 THE E (RATION DATE THER F, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORD NCE WITH THE POLICY 0 ISIONS. AUTHORI ENTATIVE / / f C 198&2610 D CO ION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD�,