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HomeMy WebLinkAbout385 Greenfields Ln s * * * RECEIPT * * * Date: 01/21/16 Receipt#: 198868 Quantity Transactions Reference Subtotal 1 Excavation Permits 1098 $195.10 Total Paid: $195.10 Notes: Payment Type Amount Paid By CK#8626 $195.10 C, DI Underground Specialists Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: C, DI Underground Specialists Po Box 1098 Commack, NY 11725 Clerk ID: LYNDAR Internal ID 1098 Permit No. I ©q( ) . TOWN OF g�FFOL�- Y DEPARTMENT T ;� p HIGHWAPNcOGy Peconic Lane • . Peconic,New York 11958 '`� : (631)765-3140 '-y�'o! , ya��, APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or regulations for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws, ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized inspectors to make necessary inspections of the job site. Print or Type 1. C4ti/5IDi ) Name of Applicant Phone Number Address of Applicant 2. % COL V6a4-1Li (v if439 5160 ?-r^V>POBOX OCa M441161-‘4,1 /V l/7z5.' Name of Contractor Phone Number Address of Contractor 3. P. Gm2ir✓iC3y i iGzl�S L/y 61,5 A su.6strr$r✓Y) Name of Property Owner Requesting Service(if applicable) Address of Owner 9 // r 4. GLf/1_ 025/ 'GL d Gt 6 TY07'n/Caen-4f/ Q 1't rack w14-1.OarAt € zs I ZSR/z/rl G/�i� � 0 Wo Description and Location(Street 4umber,Hamlet,Cross Street) { #/1/5 (a) Is construction located within 75 feet of tidal wetlands? *Ye• No *If yes,other Town permits may be required. arlcc42S NOTE: All information requested by this lope Signature of Applicant Application/Permit Form is Required for a complete application! '7/ lC, 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.: District 1000 , Section , Block , Lot 7. Starting Date: Completion Date: 8. Work Schedule: Phase ompletion Date Excavation //Z/t/ Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement / Complete Application. GvkorX /o Cole� rzha 9. Under which authority is application being made: fdYed 6on Somme' See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being mo ified. 10. Estimated Cost of Proposed Work: $ 0 11. Remarks: 6,M 7 (L4 ,,Gd (�p" • G� -6e) 7 3g5 a/a/m rt D-39 4f0 1 of 3 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 for Each Project Location - $150.00 A Project Location would include each Bell Hole and/or every road opening or excavation within any 50'Radius whether or not they may be inter-connected by open trench or directional boring. The total number of Project Locations shall be subject to the approval of the Highway Superintendent. 00 Al. f /Service Connections excavations @$20.00 $ 20 No. A2. /Additional Excavations same service @$10.00 $ No. B. Excavations 18"in depth or less _,—,, a . 112 0-100 L.F.=$10.00;Additional `' L.F.@$0.10 $ 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 /l {� /v- /0 TOTAL$ ` F. Notice to public utilities proof must be provided and Shall be attached to this application prior to issuance of permit. * * * * * * * * * * * * * * Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: im accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if y)attached hereto. SUPERINTEND NT of .IG" A : ` TOWN OF S T ,Y, Pi � •'K // incen x/ap l // ( Date 1 Date Received by the Town Clerk I 110(I 1 (P Date Permit Issued I Zl.11(o Permit No. 1098 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 L • Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified l" 2nd 3rd 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) HES Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 , itte Referral Form CLAIM/Form Number:' REFER TO: CONSTRUCTION _ ETS/Remedy Ticket. DSTX00089977508 I Facility!Dept.: RIVERHEAD OSP Supervisor Dennis Greene 516 805-7446 iTech/Nextel2236 Luigi Tlberia 516 779-1076 i REASON FOR WORK 1: CONSTRUCTION REASON 2 CLI Pole* PS Amp' Tap DESIGN INFO ONLY Design Type DESIGN TYPE 1 2(ReslComm) Existing/New Subscnber Subscribers Name Patrica Garvey CORP 7839 Account 379388-02 Date January 12,2016 Address. 385 Greenfields Lane Phone 631-765-8747 Gnd/Map 611-97 State/Town I SOUTHOLD ? X-Street Tucker Lane Hagstrom (include TDR printout if cable replacement is needed)-- - Head End Node CH2 CH70 CH119 603 MHz 693 MHz 747 MHz Babylon THIRD PARTY Tap. 10 11 12 12 12 Center Moriches DAMAGE? N� Spliced Point: Central Islip Ground Block. Coram ! Third party Damage information East Hampton Renal Work(hst pole 'number(s)8 nearest house TYPE CABLE REPLACEMENT East Quoque Time worked Hicksville Tech# (note if reg,OT or DT) Pole#s House Ss Huntington 1st Riverhead Tech MDU Lockbox referral information - --- --- - Roslyn 2nd South Hampton Tech Lock Box Size: I Box Cover Needs Replacement I Southold X9B012-H23 3rd Lock Box Location: Problem I St James Tech Lock Location on Box: - #of driveways(to replace from point to [ Vau(ts:r 1 Pedestals:I I point) Total is there a TEMP cable In place at this time? I NO I Ftg Does the repair require a ROAD CUT? YES I Ftg - 30 feet replacement DRIVEWAY SHOT YES ft OF DRIVEWAYS 1 footage CONSTRUCTION TYPE UNDERGROUND CABLE TYPE• 500P3 FOOTAGE 370 feet Customers Is this a house drop? NO What is the drop length? Affected Is there a spare cable? NO Is the drop Aenal or U/G? Output of split on Tucker Lane to input of LE by 145 Fittings and equip been changed? NO Comments Greenfields Lane 500 feeder has a fault in it. Fault is in Is this a dangerous situation? NO driveway of 150 Greenfields Lane. - - ` SIGNAL-LEAKAGE MEASUREMENTS :. r C L I Level @ 10 feet before repair meas Location and repair of leak if above 2OaV/m If leak Is generated from plant Identity the approx location of the leak and document of information on Hamel I TapI—I[ I Dropl I Feeder) I Trunk' this form. CLI Level @ 10 feet after repair meas Pad Value Of used) Dispatch VS DESIGN REFERRAL All design referrals must have take off poles and footages Drawing must have exact location of cable drops and feeder if needed Detailed explanation Output of split on Tucker Lane to input of LE by 145 OS? q2 /31 53 Greenfields Lane 500 feeder has a fault in it. Fault is in driveway of 150 Greenfields Lane. - rct?IST) gig IY E r, \ 7� S 1 (Construction Use Only) "' -- --Date Received:' Tech(s)/Contractor assigned to: " ` . Date Assigned: *NCR(not const.related) NCR=Given Back To; '` - "-- ` NCR-Date Given Back:- —' Actual Comp.Date. - Tech(s)/Contractor who completed the work - Completion Code Construction Completion Comments: Needs Activation Y/N •NCR requires comment x'oozACf- Zs-'/ 1 OF 34n91.7G'L=D uU ei419Z6US/Q/V &Sa T/%/0 / g €-Airib2.O S 6V, (& �/�7LLlif/L�S (04144 /e /17ZS 6,31 139 - 9r6,v L,UM Qc7 : GrAy (Aj / -767-DZ3S , ' + '7 OCr!! @_Cel(u�f,Y, eS. C& 2 x'50 0)G,Ped ftlark(fa` zit Q — - — — — — — - -O /60602.4 13St ' )0Z' kbU /,50 0 RIO a ..••••••'•41111Et CERTIFICATE OF LIABILITY INSURANCE 1/111/2016D/vYYY) 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: If the certificate holder is an ADDITIONAL INSURED, the policy(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 CONTACTMichael Bonocore NAME A. J. Bonocore Agency Inc. HONN F,I, 631-234-5595 MNe)631-234-5920 1797-48 Veterans Memorial Highway E-MAIL Islandia, NY 11749 ADpRESS, INSURER(S) AFFORDING COVERAGE NAICN INSURER A Technology Insurance Company INSURED CDL Underground Specialists Inc. INSURER B Ace American Insurance Co. PO Box 1098 INSURER C,Nat'l Liability & Fire Insurance Co Commack, NY 11725 INSURERD The First Rehabilitation Life INSURER E 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 INSR AUUL sung POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) JMM(DD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 UAMAGE IO RENTED I CLAIMS-MADE El OCCUR PREMISES(Ea occurrence) $ 100,000 X CONTRACTUALTPP1014104 4/19/154/19/16^MEDEXP(Anyoneperson) $ 5,000 , A X XCU INCLUDED R Y XERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPUES PER GENERAL AGGREGATE $ 2,000,000 RPOLICY®jEC ®LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER. AUTOMOBILE LIABILITY CEOMBBINED1SINGLE LIMIT $ 1,000,000 X ANYAUTO BODILYINJURY(Perperson) $ ALLOWNED SCHEDULED TPP1014104 4/19/154/19/16-- A - AUTOS - AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS - AUTOS (Peracadentl B $1,000 COLL X 1,000 CO? , $ UMBRELLA LIAR X OCCUR N10837327 4/19/15 4/19/16 EACH OCCURRENCE $ 5,000,000 B EXCESS UAB CLAIMS-MADE AGGREGATE $ 5,000,00(F DED I I RETENTIONS $ WORKERS COMPENSATION I STATUTE I I VP - AND EMPLOYERS'LIABILITY y��J C ANY OF ICPEILMFI IBER EXCLUDED? P'�1 N/A EL EACH ACCIDENT $ 1,000,000 (Mandatory in NH) I�JI V9WC661423 8/26/158/26/16 EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,descnbe under 1 000 000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ r r D Disability D184558 7/17/157/16/16 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached d more space is required) Replace damaged cable in the Town of Southold. Certificate Holder is Additional Insured as their interest may appear. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS P.O. Box 1179 Southold, New York 11971 AUTHORIZED REPRESENTATIVE 1 t I ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD