HomeMy WebLinkAboutOld Main Rd Permit No.
TOWN OF SOUTHOLD ry��SUFF01k�,
HIGHWAY DEPARTMENT
Peconic Lane y ;
Peconic,New York 11958 GV
(631)765-3140 '�'ol yay
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. -�cue. I�oiO�cif1 - (0 3 `4 `�-��� a - (,v I l 1)i P Co I
Name of Applicant Phone Number Address of Applicant
2, Sae's U(�A-e!T�fcx)(N.J u+tl+ 4!eS Inc- Same- - of- ( sableL-)t5+ on
Name of Contractor Phone Number Address of Contractor
3. �1A
Name of Property Owner Requesting Service(if applicable) Address of Owner See- A-+A -c—(
4. �� MO-In �� - (YM0A 4.�?UC-I-- C-15 MCL(V) -Ft-orv, Ode- Cr)
Work Description and Location(Street Number,Hamlet,Cross Street) t'ac -4 d u`l e s 1- P' - /e h+sn ��
(a) Is construction located within 75 feet of tidal wetlands? *Yes No V
*If yes,other Town permits may be required.
NOTE: All information requested by this Signature of Applicant
Application/Permit Form is
Required for a complete application! _ -
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: !� (� J����i nod P-er[VVJ- Fj�(��!!� Completion Date: Same.
8. Work Schedule: Phase Completion Date
Excavation Work Schedule
Facility Installation Must be provided
Backfill&Completion for consideration as a
Pavement Replacement 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: $
11. Remarks: S'E�(�\0.Cc' �nS � J� 1er�� nd (2D,-uI ane S '(�6(ey t sl Gn
4.
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D-39 1 C(t baa z10 9 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 - $500.00
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.
Al. I/Service Connections excavations @$50.00 $ J as
No.
A2. /Additional Excavations same service @$20.00 $
No.
B. Trench Excavations 18"in depth or less
Total Lineal Footage of Excavation; L.F.@$10.00 $
C. Trench Excavations 18"in depth to 5'in depth
Total Lineal Footage of Excavation; L.F.@$30.00 $
D. Trench Excavations 5'in depth and over
Total Lineal Footage of Excavation; L.F.@$50.00 $
E. Utility Repair Excavations @$1,000.00/Each $
No.
Additional Repairs of Same Service @$500.00/Each $
No.
TOTAL$ •
04-0
F. Official 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 High ay Excavation pe t to:
acco a wi
this application and subject to the"General Conditions"and"Special Conditions"of permi (if )atta ereto
SUPERINT E O AY
TOWN OF S U O
Vin ent Orlando
�3I�Date Received by the Town ClerkDate
Date Permit Issued !�(� C(I Permit No. 1336
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# � O
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1 St
2nd
3rd
4t'
(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
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May 0119 11:36a Bay Harbour 6312892176 p.2
.a► rD�® CERTIFICATE OF LIABILITY INSURANCE DATE(A1MI0DIYYYY)
I_ [ 05/0112019
THIS CERTIFICATE IS ISSUED ASA 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. H the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsemenL A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT John C Barry
Bay Harbour Ins Agency, Inc. 1Cv6Nn E:q. (631)758-1550 FAX p Rv; s31 289-2176
88 Waverly Avenue aDORsss Jbarry@bayharbourgroup.com
Patchogue,NY 11772 INSURERS AFFORDING COVERAGE NAIC 9
INSURERA: EV1nstQn InsuCance CoMpany 36378
lAsuRED INSURER B; Endurance American Insurance 41718
Joes Underground Utilities Inc INSURER C:
8 Gull Dip Road INSURER D;
Ridge, NY 11961 INSURERE;
INSURER F•
COVERAGES CERTIFICATE NUMBER: 00000000307651 REVISION NUMBER: 2
THIS IS TO CERTIFY THAT THE PCLICIES OF INSURANCE USTED BELOW HAVE BEEN tSSUED TO THE INSURED NAMED ABOVE=0R THE POLIC"PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMEN",TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TC WHICH THIS
CERTIFICA-E MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY-HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUS ONS AND CONDITIONS OF SLC-POLICIES.LIMITS SHCWN MA"HAVE BEEN REDUCED BY PAID CLAWS.
LTR MRTYPEOFINSURANCE ADDLSUBR POLICY NUMBER Iemmmyn FOUCYEFF POLICY
M IC�Y EXP
LIFAIrS
A X COMMERCIAL GENERAL LIABILITY Y N 3EQ3326 04/2912019 04/2912020 EACH OCCURRENCE S 1000,000
CLAIMS-MADE _x1 OCCUR CARTPRE MI E rO D-_ S 100
00
MED EXP Any ore person) f 5,000
�EFCRCNAL a ACV II.JURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
X,POLICY 1 PRa I� GEAERA_AGGP.EC0.TE a 4,000,000
�_JECTPRO. I 1 LOC PRCDUCTS-COMPn7PAGG s 4,000,000
OTHER
S
AUTOMOBILE LIABILITY COMBINEDS
OINGLE UMI- S
_LEa amdent)
OWNED
SCHEDULED BODILYIWURYtPerpersonj S
YvNED
AUTOS ONLY AUTOS BODILY INJURY(Perawdenq $
HIRED NCN-0WNED PROPERTY 17r4htAGE
AUTOS ONLY AUTOS ONLY PeraWdeml S
S
B ur:BRELLALIAe X OCCUR I ELD30000649000 04/29/2019 04/2912020 EACH OCCURRENCE S 5,000,000
• X
EXCESS LIAB C.AIa9S-MADE i AGGREGATE S 5,000,000
DED I RETENTIZNS 5
WORKERS COMPENSATION PER DTH-
ANDEMPLOYEFWtJABIUTY ,TIN STATUTE ER
ANY PROPRIETOR/PARTtIERIEXECUTIVE j
OFFICER.MEMe3t EXCLUDED? ❑ NIA E-L.EACH ACCIDENT
(Mandatory In NH) E.L.DISEASE-EAUAPLOYEE S
17adescnbe under
ORIPTtCNOFCPERATIONSbelow E.L.DISEASE-POUCYUMIT S
i
DESCRIPTION OF OPERA13ONS I LOCATIONS!VEHICLES(ACORD 101,Addillenal Renmrks Schcdule,may be attached d more space is required)
Certificate Holder is included as additional insured as per written contract.
RepairlReplace CAN lines for Cablevision.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
53095 Route 25 ACCORDANCE%7TH THE POLICY PROVISIONS.
Po Box 1179
Southold,NY 11958 AUTHORIZED REP SENTATIVE
JCB
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD
Printed by JCB on May 01,2019 at 11:34AM
May. 1. 2019 11 :04AM Specialized Insurance No. 3289' P. 2
Yi Workers' CERTIFICATE OF INSURANCE COVERAGE .
TAYE Compensation
Board DISABILITY AND PAiD FAMILY LEAVE BENEFITS LAW
PART 1,To be completed by Disability and Paid Family leave Benefits Carrier or licensed Insurance Agent of that carrier
ia.Legal Name&Address or insured(use street address only) 1b.Business Telephone Number of Insured
JOIE'S UNDERGROUND UTILITIES INC 631-484-8512
8 GULL DIP ROAD
RIDGE,NY 11961
1c,Federal Employer Identification Number of Insured
Werk Lot:allon of Insured(pnyragUfn:(tl/coverage isspecr71ca1(yNOW to or Social Security Number
colfain Im1fanrr in New Yarn Slate.ie..Wrap-up Pallay) 331212677
2.Name and Address of 8ntity Requesting Proof of Coverage 3a.Name or insurance Carrier
(Enilly Being Listed as the Certificate Holder) ShelterPolnt Life Insurance Company
TOWN OF SOUTHOLD ab.Policy Number of Entity Usted in Bax"Is'
53095 ROUTE 25 DBL260677
PO BOX 1179 3c.Polley effective period
SOUTHOLD NY, 11958 09/22/2018 l0 09/21/2020
4. Policy provides the folloWing benefits:
® A.Both dtsability and paid family leave benefits.
B.Disability benenis only.
C.Paid family leave benallis arty,
5. Policy covers:
21 A.All of the employers emplayees eligible under the NYS Disability and Paid Family Leave Benefits Law.
rl B.Only the following class or classes of employee's employees:
Under penalty,of pat)ury,t carlify that i atn an authorized representative or licensed agent of the insurance carrier referenced above and that the named
insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above.
Date Signed 5/1/2019 By RXW,
(signature or Insurance carder's authortzed representative or NYS ticensed insurance Agent of that insurance prier)
Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer
IMPORTANT: IF Boxes 4A and 5A are checked,and this form is signed by the insurance cardees authorized representahve or NYS
Licensed Insurance Agent of that carrier,this certifoate is COMPLETE.Mail it directly to the certificate holder.
If Box 48,4C or 58 is checked,this certificate Is NOT COMPLETE for purposes orSeclion 220,Subd.8 of the NYS
Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation
Board,Plans Acceptance Unll,PO Box 5200,Binghamton,NY 13902.5200,
PART 2.To be completed by the NYS Workers'Compensation Board(only If Box 4C or 5B of Part i has been checked)
State of New York
Workers' Compensation Board
According to information maintained by the NYS Workers'Compensallon Board,the above-named employer has complied with the
NYS Disability and Paid Family Leave Benefits Law with respect to all of blather employees.
Date Signed By
(signature of Authorized NYS Workers'Compensatlon Board Employeel
Telephone Number Name and Tills
Plsase Note:OntyInSU nce carriers licensed to write NYS disability and paid family leave benefits Insurance policies and NYS licensed Insurance
agents of those Insurance carriers are authorized to issue Farre Dki-120.1.Insurance brokers are NOTauthorized to Issue this form.
DD-120.1 (10.17)
DS-120-1 (10-17)
May. 1, 2019 11 :04AM Specialized Insurance No- 3289 P. 1
New York State Insurance Fund
Workers'Compensallor:&Disability l3enefil8 Specialists Since 1914
8 CORPORATE CENTER OR,3RD FLR,MELVILLE,NEIN YORK 117473129
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
A A A A A 331212677
SPECIALIZED INSURANCE 8
SERVICES INC
204 ROUTE 112
PATCHOGUE NY 11772 SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
JOES UNDERGROUND UTILITIES INC TOWN OF SOUTHOLD
8 GULL DIP ROAD 53095 ROUTE 25
RIDGE NY i 1961 PO BOX 1179
SOUTHOLD NY 11958
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
12157 309.2 900607 08110/2018 TO 08/10/2019 5/1/2019
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2157 309-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW VVITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:IANIiIUtAI.NYSIF,COMICERT/CERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVED CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED CORPORATION.
JOSEPH ROBSON(PRES)OF
JOES UNDERGROUND UTILITIES INC
(ONE PERSON CORP)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY_
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND.UNDERWRITING
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
I. Permittee's Contractors to Comply with Permit Requirements: The Permittee is responsible for
informing its independent contractors, employees,agents and assigns of their responsibility to comply with
this pennit, including all special/site specific and general conditions imposed by the Highway
Superintendent while acting as the permittee's agent with respect to the permitted activities,and such
persons shall be required to comply with all permit requirements.
2. No Ril4ht to Trespass or Interfere with Private Property Ril4hts: This permit does not convey to the
permittee any right to trespass upon the lands of adjacent property owners in order to perform the permitted
work nor does it authorize the impairment of any rights,title, 6r interest in real or personal property held or
vested in a person not a party to the permit.
3. Protection of the Highway and Future Highway Maintenance: If future operations or highway
maintenance projects by the Town of Southold require an alteration in the position of the utility,structure
or work herein authorized,or if, in the opinion of the Highway Superintendent the work performed under
this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health,
safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility,
structure,fill,excavation, or other modification of the highway hereby authorized shall not be completed.
Additionally,the permit may be revoked if the Highway Superintendent finds that the issuance of the
permit was illegal or unauthorized or that the applicant failed to comply with any of the terms and
conditions of the permit or Chapter 237 of the Town Code.
4. Revocation of the Permit by the Highway Superintendent: If the Highway Superintendent deems it
necessary to revoke this permit and the project hereby authorized has not been completed,the applicant
shall,without expense to the Town and to such extent and in such time and manner as the Superintendent
may require,remove all or any portion of the uncompleted utility,structure or fill and restore the site to its
former condition.
5. Notice of Commencement: At least 24 hours prior to commencement of the project,the permittee and/or
contractor shall notify the Town Highway Department in writing that they are fully aware of and
understand all terms and project conditions of this permit. Upon completion of the work,the contractor
shall provide photographs of the completed work to the Town Highway Department and request a Final
inspection.
6. Storage of Equipment&Materials: The storage of construction equipment and/or materials shall be
confined within the project work area and/or adjacent areas where permission/legal access has been
obtained in a manner that does not interfere with normal highway traffic.
7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility
mark-outs and shall take all precautions to protect same. Damage to existing utilities shall be the
responsibility of the contractor and shall be repaired at the contractor's expense.
8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town
Board prior to closing a road. Temporary lane closures may be permitted with the approval of the Highway
Superintendent. This item will included but not be limited to the installation of appropriate signage and
flag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen,
emergencies require immediate notification of the Highway Department and shall be limited to immediate
and/or expedited restoration of the Work Zone.
9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job
site on a daily basis. All stockpiled soil as well as all other project materials that will be staged within the
Right-of Way must be delineated with reflective signage or other means to meet the minimum requirements
of the NYS DOT Construction Standards.
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
(Continued)
10. Install,Maintain Erosion Controls: Required Erosion Control Measures(i.e. silt fencing) is to be placed
on the downslope edge of any disturbed area. This sediment barrier is to be put in place before any
disturbance of the ground occurs and is to be maintained in good functional condition until thick vegetative
cover is established.
11. Clean Fill Only: All project back-fill shall consist of clean sand,gravel or soil (NOT asphalt,slag,flyash,
broken concrete or demolition debris). All unsuitable soils excavated at the site(i.e.Clay,Bog,etc.)are to
be removed from the site and not used to backfill any excavation within a Town Highway.
12. All Areas of Soil Disturbance : All areas of soil disturbance resulting from the approved project shall be
stabilized to the satisfaction of the Highway Superintendent inunediately following project completion. If
the project site remains inactive for more than 48 hours or planting is impractical due to the season,then
the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions favor
germination.
13. Backfill&Compaction of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a
well-defined moisture density relationship as determined to be in accordance with ASTMD 698. Fill shall
be placed in maximum lifts of twelve(12")inches thick and shall be mechanically compacted to a Ninety-
five(95%)percent maximum dry density. Suitable hydraulic compaction by water jetting at three-foot
intervals will also be permitted subject to a project specific approval by the Highway Superintendent.
14. Restoration of the Road Shoulder Area: All man-made improvements located within existing road
shoulder areas must be protected to the greatest extent practical. Items would include but not be limited to
driveway&private road aprons,mail boxes, sprinkler systems,trees and ornamental plantings.
Excavations through driveways and private road pavements must be reconstructed to meet all requirements
of Southold Town Highway Specifications. All pre-existing road shoulder improvements that have been
disturbed during construction must be replaced or repaired by the contractor to the satisfaction of the
Highway Superintendent.
15. Schematic Plans with all Technical information and Scope of Work: To reasonably and adequately
describe the proposed work,accurate schematic site plans must be provided to show or indicate all
proposed construction activity required under this permit. All Pavement surfaces scheduled for excavation
must be saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of bell holes or width
of trenching must be indicated by dimension or labeling. This schematic site plan must provide details on
all restoration required to meet the requirements of these General Conditions and requirements found in the
Southold Town Highway Specifications.
16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner;
(Note-When Concrete Pavements are Present,Please review Restoration requirements with the Highway Superintendent)
a) Complete all back-fill &soil compaction work as needed to provide a suitable sub-base;
b) Over-cut existing asphalt bell hole or trench by twelve(12")inches on all sides;
c) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification);
d) Install a two and one half(2.5")inch compacted lift of Asphalt Base Course;
e) Install a one and one half(1.5")inch of Asphalt(Type 6)Wearing Course. (Provide AC at all joints)
All work listed herein must meet the minimum requirements of the Southold Town Highway
Specifications.
17. Trenching of Pavement Surfaces Exceeding One Hundred (100') Feet in Length: All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
# 16 as noted above. Once all pavement reconstruction is completed to the satisfaction of the Highway
Superintendent,the entire road section and/or width of road over the entire length of trench shall be
repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder).
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