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Home My WebLink About1650 Fleetwood Rd Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 05/18/11 Receipt#: 103037 Transaction(s): Reference Subtotal 1 1 Permits 708 $180.00 Check#: 9853 Total Paid: $180.00 Name: AM, Long Island Inc P O Box 2507 Southampton, NY 11969 Clerk ID: LINDAC Internal ID: 708 Permit No. TOWN OF SOUTHOLD ' HIGHWAY DEPARTMENT RE �� ' P.O. Box 178 Peconic, New York 11958 2011 (631)765-3140 , SouthoW Towm Cark 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 Type 1'S 49&X JU Z �',o ti �a ti 1, k l 119�`I Name of Applicantt� Address of Applic nt 2. _1� ,,L __ `,� 6J� 6/?Q7��c / A / C/<4 tome Name of Owner of Premises ®® Address of Owner / 3. of Work Description and Location(Street Number, an-let, Cross Street) \\ - (a) Is construction located within 75 feet of tidal wetlands? *Yes No �e *If yes, other Town permits may be required. 4. Builder's License No. Plumber's License No. Electrician's License No. Other Trade's License No. cell a SlG - �/4- 9a 7A �Z 7' 17 7 SignatW 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 / 3 7 _______,Block_ _� Lot 13 7. Starting Date: 7� I I _ Completion Date: //I 8. Work Schedule: Phase Completion Date Excavation by&r 4 ,r,/ Facility Installation Z„ ,y,,,- R." c e G n Q Backfill&Completion con- k2 l c,n S4 m e Pavement Replacement 9. Under which authority is application being made: 10. Estimated Cost of Proposed Work: $ 3 SD 11. Remarks: 2 eeveS w�Jl ¢ G�e� yrl`[2r 7"!tQ � X04 4-1 D-39 1 of 3 12. Insurance Coverage: (Attach Copy) (a) Insurance Company: (b) Policy#: C G Y 09 ? 90,32 C e !/ 0 t13 W 3 (c)State whether policy of certification on file with the Highway Department: Ve s (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 $150.00 Al. / /Service Connections excavations @$20.00 $ No. A2. I /Additional Excavations same service @$10.00 No. B. Excavations 18" in depth or less 0-100 i.f. =$10.001- Additional_ i.f. @$0.10 $ C. Excavations 18" in depth to 5' in depth 0-100 i.f.=$30.00;Additional i.f. @$0.30 $ 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$ /7`,0.60 F. Notice to public utilities proof must be provided and attached to this application prior to issuance of permit. �'4 s e # 70 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. SUPERINTENDENT OF HIGHWAYS TTPWN O SOUTHOLD, W YORK Peter W.Harris A , Date Received by the Town Clerk 5 l �� D to Date Permit Issued �� Permit No. 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 lst 2nd 3 rd 4th (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 J&M Long Island, Inc. P O Box 2507 (631) 287-0580 Southampton, NY 11969 283-5898 e lee �-rC —s Q' w Q, � 05/17/2011 08:31 FAX Z0001/0001 ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY( 05/17/2011 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION H F WRIETH INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 368 SOUTH WELLWOOD AVENUE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. LINDENHURST, NEW YORK 11757 INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A GENERAL CASUALTY CO OF WI J 8r M LONG ISLAND INC. INSURER B. PO BOX 2507 INSURER C SOUTHAMPTON, NEW YORK 11969 INSURER D INSURER E 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. INSKLTR INSR^Lou TYPE OF INSURANCE POLICY NUMBER DATE M/DPOLICY /YY T / LIMITS A GENERAL LIABILITY CCX 0439033 08/08/10 08/08/11 EACH OCCURRENCE $ 1.000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO REN PREMISES(Ea oc urenos i CLAIMS MADE a OCCUR MEO EXP(Any one person( S 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 2,000,000 POLICY F_jPROJECT LOC FIRE LEGAL 100,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT S i ANY AUTO UTO ONLVN EA ACC $ AA AGG S A EXCESSIUMBRELLA LIABILITY CCU 0439033 08/08/10 11 08/08/11 EACH OCCURRENCE S 1,000,000 OCCUR CLAIMS MADE ( AGGREGATE S 1,000,000 S DEDUCTIBLE S RETENTION S OTH $ WORKERS COMPENSATION AND " EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ Ifysa,des ribs under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMI $ OTHER UL5(I;KIPTIUN UP U JI-E5 I EXCLU51ON3 ADDED BY ENUOK3 6MENT I SPECIAL PROVISIONS EXCAVATION CONTRACTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF SOUTHOLD HIGHWAY DEPARTMENT DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN .O. BOX 178 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL PIMPOSE NO OBLJGATION OR LIABI Y OF ANY KIND U THE INSURER,ITS AGENTS OR P.O. BOX NEW YORK 11958 REPRESENTATIVES. AUTHORIZED REPRESENTATIV ACORD 25(2001/08) RD CORPORATION 1988