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Home My WebLink About635 Kimberly Ln (2)Permit No. l TOWN OF SOUTHOLD -Afiek HIGHWAY DEPARTMENT Peconic Lane 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 237 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, the attached "General Conditions of Permit' and "Special Conditions", if any and to permit authorized inspectors to make necessary inspections of the job site. Print or Type 0 4. &/ OA,. o &iL &Pt o Name of Applicant Phone Number a1v Name of Contractor Phone Number /,�3l - 4- 20M of Applicant 1� 100 5100 FAQ TP6/2 r /V Address of Contractor Name of Property Owner Requesting Service (if applicable) Address of Owner R&IALH(IZ� Sell s. -TV C14A-L 6- 0U r/"I&^L. C�� a e-r�e ,v P=6 xfn»v /Zo ,qc,0 11,//0go� Work Description and Location (Street Number, Hamlet, Cross Street) (a) Is construction located within 75 feet of tidal wetlands? * Yes No X *If yes, other Town permits may be required. NOTE: All information requested by this Application / Permit Form is Required for a complete application! Signature o Applicant :22_ %�� Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the location of all proposed excavations and relationship to adjoining premises, public streets or areas, and give a detailed description of all site and pavement restoration work. (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. 7. Starting Date: 8. Work Schedule: District 1000 , Section -70 Block % �j Lot 11�-Oe%P— / Completion Date: Phase Excavation Facility Installation Backfill & Completion Pavement Replacement Completion Date Work Schedule Must be provided for consideration as a Complete Application. 9. Under which authority is application being made: See Town Code Chapter 237 (E) - Provide Resolution by, or authority from, the Utility being modified. 10. Estimated Cost of Proposed Work: $ coo, 11. Remarks: "7'tJ S i 9c -C- .9 `� �L4OUX tt D-39 ;;C47—V6,77 ek-.- 2 ' S1' A% n-�, 7o e- e- t" vim CLT-. S /L.✓ L r` o f 12. 'Insurance 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: Any Loss including Bodily injury, property or commercial injury caused by or attributable to the work performed: $1,000,000 per Occurrence and $ 2,000,000 general aggregate. 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• / Additional Excavations same service @ $1'0.00 $ No. B. Excavations 18" in depth or less 00 0-100 L.F. =$10.00; Additional..' U L.F. @ $0.10 $ 13 C. Excavations 18" in depth to 5' in depth 0-100 L.F. = $30.00; Additional L.F.@ $0.30 $ D. Excavations 5' in depth and over 0-100 L.F. = $50.00; Additional L.F. @ $0.50 $ E. Utility Repair Excavations @ $10.00 $ No. Repairs same service @ $5.00 $ Additional u L� F. Notice to public utilities proof must be provided and J TOTAL$ / L� Shall be attached to this application prior to issuance of permit. m/9✓1-� c-- O fs e * * * * * * * * * * * * * * 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 and subject to the "General Conditions" and "Special Conditions" of permit (if any) attached hereto. Date Received Received by the Town Clerk ate L/-- / – - Date Permit Issued ��(�, %� Permit No./ NOTE: Permit expires one (1) year from date of issuance. No work to start without 24 hour notice to Superintendent of Highways. Permit must be available at all times for inspection, on site, during construction. D-39 2 of 3 Copy Distribution: Highway Department Engineer (with page 3) Applicant Town Clerk (Original) Inspection Date 1st 2nd 3rd 4th INSPECTOR'S RECORDS 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 Findings (use code) REMARKS Permit # Applicant Notified (To Permit Clerk) 3 of 3 11080 VAU-L F 6M Gm /<P1.1amn�--i re V'3 L AA-, 82 s 1 163.7 a 40 � q X O 82 s 1 163.7 a 40 From: ��-t 06/17/2014 15:07 #090 P-002/006 CERTIFICATE OF LIABILITY INSURANCE 6/171/2014 ' INUMBEK: THIS CERTIFICATE 18 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: M the certificate holder Is an ADDITIONAL INSURED. the policy(ies) must be endorsed. N 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 Btu of such s), PRODUCER A. J. BOUOCOre Agency Inc. 1797-48 Veterans Memorial HighwayfAIM Islandia, NY 11749 WNTACT -631-234-5595 A+c.No.631-234-5920 ADDRESS: 011911101011s) AFFORD= COVERAGE MAICa INSURED American Underground Utilities Inc._ P.O. BOX 900 Eastport, NY 11941 714-0369 bill cell r ;:QTI0lI-ATC Lu lance. INSURER A: TRCHNOLOGY INSURANCE CO • • on re as o o s, INSURER B r a o�erce n ne ry ns ospaay INSURER C INSURER D : Zur c American Insurance aayPH:325-1797;FAX:801-2831 INSWERE:Hart or L e Insuranco.631 7- WSURERF:COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVEFORHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT O 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. .TR TYPE OF INSURANCE WVMD POLICY NUMBER OLMM'rS RAL LIABILITY X COMMERCIAL GENERAL LWBILITY FF� s 1,000,000 s 100,000 CLAIMS -MADE Q OCCUR $ S'000 A I TPP1014207 5/30/145/30/15 PERSONAL&ADVMIdURy s 1, 000, 000 i A TPP1014207 5/30/145/30/1 GENERAL AGGREGATE S '1-600,000 GEN'L AGGREGATE LIMIT APPLIES PER!POLICY R PRO LOC AUTOMOBILE LIABILITY X ALL OWNAUTO ALL OWNED SCHEDULED AUTOS AUTOS SWNED HIRED AUTOS NON-OWNED AUTOPer PRODUCTS - COMP/OP AGG S 1, GOO , O OO $ E• aoedkd*1 s 1,000,000 BODILY M,AJRY (Per pemah) s BODILY INJURY (Per accident) $ acddaq $ BLKS Lua g occuR CLAWS -MADE NIA BE 015820104 WC 005-81-5576 83378-001 �-rS14925001 5/30/145/30/1 6/16/146/16/15 01/01/14 12/31/14 $ EACH occuRRENce s 5, 000, 000 {RETENTION S 10 0 0 0 AR=KERS ENSATIONS LIABILITY yrN ANY rat PRIETORPARTNEftEMCUTWE C OFFR:ERAIEMeER EXCLUDED, tMiidpo�M�+) n� yes� deeaibe tsrdar DESCRIPTION of OPERATIONS below D DISABILITY 8 !DISABILITY Lc REGATE s 51000,000 E.f �,, 000, 000 7E E.LOY s 1,000,000 - ELLIMB s 1.000, Q00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addttionsl Remarks Schedule, if mere space is required) Project: Cablevision Repair. The Certificate Holder is Additional Insured as their interest may appear. Town of Southold P-0. Bos 1179 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southold, NY 11971 ACCORDAN4CEWIVTHDTHE POLIICC VPROVIS"NS E WILL BE DELIVERED IN ACORD25 (2010/05) AUTHORIZED REpRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD From: 06/17/2014 15:08 #090 P.003/006 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW 1 PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Avent of that rarrior 1 a. Legal Name and Address of Insured (Use street address only) American Underground Inc. P.O. Box 908 Eastport, NY 11941 I b. Business Telephone Number of Insured 631325-1797 Ic. NYS Unemployment Insurance Employer Registration Number of Insured td. Federal Employer Identification Number of Insured or Social Security Number 13-4337136 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Zurich American Insurance Co. Town of Southold 3b. Policy Number of entity listed in box "I a": P.U. Box 1179 5283378-001 Southold, NY 1 ] 971 3c. Policy effective period: I/1114 to 12/31/14 4. Policy covers: a. a All of the employer`s employees eligible under the New York Disability Benefits Law b. ❑ Only the following class or classes of the employer's employees: 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 NYS Disability Benefits insurance coverage as described above. Date Signed_0ti/l7'I__ _ 4 _ By_�� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthet insurance carrier) Telephone Number _631 234-5595 Title Secretary,Treasurer I IMPORTANT: If box "4a" is checked, tied this fora is signed by the insurance carrier's autborind representative or NYS Liceased Insurance Agent of that carrier. this certificate Is COMPLETE. Mail b directt)• to the certincate holder. If box '4b" is Checked, this certificate is NOT COMPLETE for purposes of Section 228, Solid. B of the Disability Benefits Lew. It must be mailed for cont letioo to the %'orkers' Compensation Board, DB Plans Acceptance trait. 29 Parse Street. Alban New York 12297. PART 2. To be completed by NYS Workers' Compensation Board Oa if box "4b" of Part 1 has-been checked State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed_______ By (Signature of NYS Workers' Compensation Board Employee) Telephone Number _ _ Title Please Note. OnA insurance carriers licensed to write NYS disabi/ih' benefits insurance policies and NYS licensed insurance agents of those insurance carriers are aulhorized w issue Form DB -120. /. Insurance brokers are NOT authorized to issue this form. DB -120.1 (5-06) From: 06/17/2014 15:09 #090 P.005/006 STATE- OF NEW YORK WORKERS* COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE I a. Legal Name and address of Insured (Use street address only) ib. Business Telephone Number of Insured 1-631-325-1797 American Underground, Inc. PO Box 900 1 c. NYS Unemployment Insurance Employer Registration Eastport, NY 11941 Number of Insured Work Location of insured (Onto required tf coverage is speciftcalty Id. Federal Employer Identification Number of Insured or limited to certain locations in New fork State, i.e. a Wrap -Up Policy) Social Security Number 13-4337136 2. Name and Address of the Entity Requesting Proof of 3s. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) AIG Town of Southold 3b. Policy Number of entity listed in box "1a": P.O. Box 1179 WC 00541-5576 Southold, NY 11971 3c. Policy effective period: 6/16/14 to 6/6/15 3d. The Proprietor, Partners or Executive Officers are: X included. (Only check box if all parumwoliicers included) all excluded or certain partnerstofficers excluded. 3e. Demolition is: (Detention of Demolition on Reverse) r included. i_ excluded. tnra cerunes inat me insurance carrier indicated above in box "3" insures the business referenced above in box "I a" for workers' compensation underthe New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also not fi, the above certif tate bolder wuhin 10 days IFa policy is canceled due to nonpayment of premiums or within 30 dabs IF there are reasons other- than nonpayment of premiums that cancel the policy or eliminate the insured from the colvwge indicated on this Certificate. (These notices may be sent by regular mail.) Othenvise, tkis Certificate is valid fora maximum of one year after this form is approved by the insurance carrier or its licensed agent Please Note: Upon the cancellation orthe workers' compensation policy indicated on tbb form, if the business continues to be named on a permit, license or contract Issued by a eerdfleate holder, the business most provide that terdficate holder with a new Certificate of Workers' Contpensatian 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: _ Michael A Bonocore (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 1�1106/ 17/14 (Signature) Wate) y_ Title: Licensed Telephone Number of authorized representative or licensed agent of insurance carrier: _(631) 234-5595 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C. 105.2 form. Insurance brokers are NOT authorized to issue it. 0-105.2 (12-03)