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HomeMy WebLinkAboutEagle Nest Court �f TOWN OF SOUTHOLD �J ,��, 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 /� I. L �1 �l S/t9 6� A 2 an Ic�4�� (tel t l���L(�f2l�C>x�✓J (� ?`L!7`/ 1J3 Name of Applicant Phone Number Address of Applicant Name of Contractors � Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable)) Address of Owner 4. V53.T-00 �rl[ ?4,t-t'Utitc'f� /o 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. / �/��• �l �, NOTE: All information requested by this Signature of App ant Application/Permit Form is n^0 l Required for a complete application! ,� HIL7 �E1 " 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: 60?`&Ly-c-a/op7'(fir- ��2�"Z �' Completion Date: 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. r� 9. Under which authority is application being made: �� C,�1�/�/O 4--l" L See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. VP� ©v 10. Estimated Cost of Proposed Work: $ 13 Do 11. Remarks: [ 0-Er L�Id U"cam Be IL-6-— N p �;o/t,.< [Q—, �-'uc9/J W.•Q.../ D-39 1 of 3 W- ,urance Coverage: (Attach Copy) (a) Insurance Company: v WG��`� ✓��./ �� '`� (b) Policy#: VfAlk Ai`'"�'� A7:6&v t (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$2,000,000 general aggregate. 13. Security: (a)Surety Bon VI-UOQ/or Certified Check provided in the total Amount of$ (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 $ ;514V g No. A2. 'Additional Excavations same service @$10.00 $ No. _3 4!;Vw` r— B. Excavations 18"in depth or less�`j'' I C 0-100 L.F.=$10.00;Additional a 43 L.F.@$0.10 $ -f° A-o 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 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: ATH with this application and subject to the"General Conditions"and"Special Conditions"of permre SUPERINTETOWN OF S V ncen . Orlando ( Date Date Received by the Town Cl �j ( / 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: Permit# Highway Department Engineer (with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1st 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) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 ACC® DATE(MMIDDIYYYY) `.� CERTIFICATE OF LIABILITY INSURANCE 5/24/2017 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 WANED,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 CONT CT NAW Michael Bonocore A. J. Bonocore Agency Inc. QVC.No . 631-234-5595 A/cNo:631-234-5920 1797=48 Veterans Memorial Highway E-MAIL ADDRESS: Islandia, NY 11749 INSURER(S) AFFORDING COVERAGE NAICO INSURER A:American Southern Home Ins. Co INSURED American Underground 'utilities Inc. INSURER B:Ace American Insurance Company P.O. Box 900 INSURER c•NYS IF Eastport, NY 11941 INSURER D:-HartfOrd Life Ins. Co. INSURER E• ! INSURER F: i 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 j 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 TYPE OF INSURANCE AOGL SUER POLICY E LI EXP LTR 6 INSR WVG POLICY NUMBER MRMDD MANDD LIMITS t GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 3 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 51000 A 88A6GL0000117 05/30/16 05/30/17 PERSONAL&ADV INJURY $ 1,000,000 X Contractual 88A6GL0000117 05/30/17 05/30/18 GENERAL AGGREGATE $ 2,000,000 GEN'L,AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/l7P AGG $ I,O 0 O'000 XRO ? POLICY P - J CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1"000,000 X ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 88A6CA0000026 05/30/16 05/30/17 V A AUTOS NON OWNED 88A2CA1000747 05/30/17 05/30/18 X HIRED AUTOS, XAUTOS BODILY INJURY(Per accident) $ PROPER DAMAGE AUTOS Per accident $ $ & X UMBRELLA LIAB ]( OCCUR EACH OCCURRENCE $ 5,000,000 b B EXCESS LIAB N10839713 003 05/30/16 05/30/17 CLAIMS-MADE N10839713 004 05/30/17 05/30/18 AGGREGATE $ 5,000,000r_tf DED I X I RETENTION$10,0 0 0 $ WORKERS COMPENSATION X WCSTATU- OTH. 1 AND'EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE Y'" 24065955 01/04/17 01/04/18 E.L EACH ACCIDENT $ 1,0001-000 C, OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E L DISEASE-FA EMPLOYE $ 1,0001000 If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 1,000,006 D DISABILITY LNY814925001 01/01/17 12/31/17 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) The Certificate Holder is listed as the Additional Insured as their interest ` may appear. CERTIFICATE HOLDER CANCELLATION Town of Southold 1i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O. BOX 1179 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i ©1988-2010 ACORD CORPORATION. All rights reserved. 888 ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD 1 rl STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE-NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier Ia. Legal Name and Address of Insured(Use street address only) lb.Business Telephone Number of Insured 631325-1797 American Underground Inc. 1 c.NYS Unemployment Insurance Employer Registration P.O.Box 900 Eastport,NY 11941 Number of Insured 1 d.Federal Employer Identification Number of Insured or Social Security Number 13-4337136 2. Name and Address of the Entity Requesting Proof of 3a. Name.ofInsurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Life Insurance Company 3b.Policy Number of entity listed in box"I a": Town of Southold LNY814925001 } P.O.Box 1179 Southold,NY 11971 3c. Policy effective period: z 1/1/17 to, 12/31/17 4.Policy covers: a.X 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 5/24/17 By �`� ' - (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) g Telephone Number 631234-5595 Title Secretary/Treasurer IMPORTANT: If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed for completion to the 1Vorkers'Compensation Board DB Plans Acceptance Unit 20 Park Street Albany,New York 12207. PART 2. To be-completed by NYS Workers' Compensation Board(Only if box"4b"of Part 1 has been checked K State Of New York ; Workers' Compensation Board ff 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. t fi Date Signed By (Signature of NYS Workers'Compensation Board Employee) i; Telephone Number Title i Please Note.Only insurance,carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) €r 3; STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured(Use street address only) 1 b.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(Only required if coverage is specifically I d.Federal Employer Identification Number of Insured or limited to certain locations in Nein York State, i.e a Wrap-Up Polio) 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) New York State Insurance Fund Town of Southold 3b.Policy Number of entity listed in box"la": P.O.Box 1179 24065955 Southold,NY 11971 3c. Policy effective period: 01/04/17 to 01/04/18 3d. The Proprietor,Partners or Executive Officers are: X included. (Only check box if all partnerstofficers included) ❑ all excluded or certain partners/officers excluded. 3e. Demolition is: (Definition of Demolition on Reverse) ❑ included. ❑ excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' ; compensation under the 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"T'. The Insurance Carrier will also note the above certificate bolder within 10 days IF a policy is canceled due to nonpayment ofpremiu►ns or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured fi•on: the coverage indicated on this Certificate. ('These notices may be sent by regidar mail.) Otherwise,this 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 of the workers'compensation policy indicated on this form,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 for 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: 76fG � 05/24/2017 (Signature) (Date) Title:Secretarv/Treasurer Telephone Number of aulthorized 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-105.1 form Insurance brokers are NOT authorized to issue it. C-105.2(12-03) a * * * RECEIPT * * * Date: 06/14/17 Receipt#: 222281 Quantity Transactions Reference Subtotal 1 Excavation Permits 1215 $20450 Total Paid: $204.50 Notes: Payment Type Amount Paid By CK#35100523 $204.50 American, Underground Utilities/Cablevi Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: American, Underground Utilities/Cablevision P O Box 900 Eastport, NY 11941 Clerk ID: BONNIED Internal ID• 1215