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HomeMy WebLinkAboutCrown Land Ln Permit No. tbo TOWN OF SOUTHOLD HIGHWAY DEPARTMENT „moo °ate Peconic Lane Peconic,New York 11958 0 (631)765-3140 �iol �oo� 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 p Name of Applicant p j Phone Number l�Address of Applicant /� �/ 2. 1- o G 0-� �f, a`'`� (. � voce 2 3� / V / r c(4 / Name of Contract7or ) Phone Number Address of Contractor to I Name of Property Owner Requesting Service(if applicable) Address of Owner S �� 4. RrLLOC& PAuut-C7�1 117V (4&01\1 Work Description and Location(Street Number,Hamlet, Cr ss Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. 9 NOTE: All information requested by this Signature o Applicant Application/Permit Form is Required for a complete application! ( OL i 2, 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: 0L.7 g b4/ :&D Completion Date: 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement /y Complete Application. 9. Under which authority is application being made: �6Q �1/'/Sl �✓ ! t'4l �' — See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 1C9 10. Estimated Cost of Proposed Work: $ 0o~ 11. Remarks: D-39 1 of 3 12. Insurance Coverage: (Attach Copy)A9 0-76--t r–+� �O�r/4 tr— (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 exc on 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. /Service Connections excavations @$50.00 $ _ No. 0 A2. 9�- /Additional Excavations same service @$20.00 $ '04 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. TOTA-L 4C) 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 Highway Exca ation permit to: accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if )atthed he eto SUPERINTEND G S TOWN OF SO V' cent rlan o W819 Date Date Received by the Town Clerk l 1I$ �� Date Permit Issued I I I Ia- 161 Permit No. 3 6 3 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# l 36 3 Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1 St 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 1 1 1 A I DATE(MM/DD/YYYY) CERI'MCATE OF LIAR TY NSURANCE 110/09/19 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: Ifthe 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 endorsements). CONTAi TM hael $Onocore PRODUCER A. $onocore Agency Inc. PHONE 631-234-5595 631-234-5920 Wr WQ 991 - 1797-48 Veterans Memorial Highway -ADD" re a7bonocore.com Isl.andla, NY 11749 INSURERS AFFORDING COVERAGE NAIC# INSURER A. Psermmn Southern Home Insurance Company INSURED American Underground Utilities Inc. INSURER B'American Alternative Insurance Corp P.O. Box 900 IUSURER C Ace American Insurance Company INSURER D TAesco Insurance Company Eastport, NY 11941 INSURER E Hartford Life Insurance Co. NSURER 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 BYPAID CLAIMS RUDE-5UI3K POLICY EFF POLICY EXP LIMITS I sR LTR TYPE OF INSURANCE INSD WVD POLICY N MBER MM/DD /DD YYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 5 100.000 CLAIMS-MADE ED OCCUR P MISES Ea occu ence 88A6GL0000117 05/30/1905/30/20 MED EXP(Anyone erson 5 5 000 A X Contractual PERSONAL 8 ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMITAPPLIESPER GENERAL AGGREGATE S 2,000,000 POLICY rMRo LOC PRODUCTS-COMP/OP AGG S 1,000,000 $ OTHER AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $ 1,000,0()o E a acc de X ANYAUTOBODILYINJURY(Perperson) S ALLOWNED SCHEDULED $$A2CA1000747 05/30/19 05/30/20 BODILY INJURY(Per accident) S $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE Pera dent S HIRED AUTOS AUTOS S EACH OCCURRENCE $ 5,000,000 UMBRELLA LIAR R OCCUR N10839713 006 05/30/1905/30/20 C EXCESS UAB CLAIMS-MADE AGGREGATE 7370 QQ/QQQ DED I X I RETENTION$10 000S WORKERS COMPENSATION PT ER OTH- AND EMPLOYERS'LIABILITY 1,000,000 ANY PROPRIETORIPARTNEWEXEOUTIVE E L EACH ACCIDENT S D OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) i TC3417404 06/16/1906/16/20 ELDISEASE-EA EMPLOYEE S 1 /Q'60/ UOU If yes,describe under E LDISE SE- OLICY LI T 5 1,000,000 DESCUIPTION OF OPER 0 S be ow E DISABILITY LNY814925001 01/01/1912/31/19 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attachedlf more space is required) The Certificate Holder is listed as the Additional Insured as their interest may appear. CE TIFIC TE HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O. BOX 117 9 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Southold, NY 11971 AUTHORIZED REPRESENTATIVE ----------------------- ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD '"Workers' Compensation Lava Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however, shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. Definition of Demolition(Box"3e."on the reverse side of this form) A building wrecking or demolition is one where a building,chimney or steeple is razed,or where a floor,exterior wall or roof is removed. If the contract involves only the removal of interior walls,partitions or the facing only of any exterior wall,it is not considered demolition. Out-of-State Companies Working in NYS--NYS Workers'Compensation and Disability Benefits Requirements for Permits, Licenses or Contracts issued by NYS Government Entities Generally,employers must have a workers'compensation policy or a combination of policies that cover each state in which they employ permanent employees to cover on-the-job accidents and disabilities. As you are probably aware,certain insurance carriers write policies that cover multiple states. "Riders"found under sections 3A and 3C on the Information Page of the policy specify the states of coverage. In addition,the operations covered in each state are identified in attachments to the policy. In addition to any other state's workers' compensation coverages, an out-of-state employer needs to be specifically covered for NYS workers' compensation insurance when there are "sufficient contacts" between that employer and the state. While there is no single determinative factor,any of the following criteria could be the basis for finding"sufficient contacts" requiring New York coverage: o a physical location within New York State; o $50,000 in payroll during a calendar year in New York State; e one or more employees(including subcontractors)with a primary work location or hired within New York State;or 0 employees(including subcontractors)working in New York State for more than 90 days during a calendar year. If an out-of-state employer meets any of the above criteria,it is required to carry a New York State workers'compensation policy. When New York is listed in Item 3A on the information Page of an employer's workers' compensation insurance policy,the employer is fully covered under the NYS Workers'Compensation Law. If insured through a private insurance carrier,the out-of-state employer must file a C-105.2--Certificate of Workers'Compensation Insurance(the business' insurance carrier will send this form to the government entity upon request) PLEASE NOTE: The New York State Insurance Fund provides its own version of this form,the U-26.3.Ifthe out-of-state employer is legally, fully self-insured in New York State, the out-of-state employer must file a SI-12 -- Certificate of Workers' Compensation Self-Insurance(the business calls the Board's Self-Insurance Office at 518-402-0247). If the out-of-state employer is participating in group self-insurance, the out-of-state employer must file a GSI-105.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance(the business'Group Self-Insurance Administrator will send this form to the government entity upon request). If an out-of-state employer does not meet any of the above criteria and has New York(NY)listed in Item 3C on the Information Page of its workers'compensation insurance policy(the Other States Insurance section),NYS specific coverage is not required and the employer may be able to use its own state's workers'compensation coverage by filing a WCIDB-101 form.[The out-of-state employer's employees will be covered under NY benefits when working in New York by having NY listed in Item 3C on the Information Page of the workers' compensation insurance policy(the Other States Insurance section).] C-105.2(12-03)Reverse ttice THIRD PARTY CLAIM/Form Number: Referral Form DAMAGE I YES 69638 REFER TO CONSTRUCTION ETS l Remedy Ticket DSTX00114162337 Facility/Dept: Riverhead Supervisor D.Greene Tech#/Cell#. ' M Henkel/6312949909 REASON FOR WORK 1: CONSTRUCTION REASON 2 Pole: PS- Amp- Tap DESIGN INFO ONLY DESIGNs JC7ype TYPE 1 2(R(ReNconun) Existing I New Suhscriber Repair Location: 375 Crovlrnland Lane CORP 7839 Account. 3124723 Date: October 10,2019 Name: Cut Cable Phone: Grid/Map- Address: 375 Crownland Lane X-Street: Main Rd Town: Cutchogue Hagstrom _ (incEDde-TD i tsrl.,totrt if cafito reAtacamalat'es naeded) -- CorpHeadend Node CH2 CH70 CH119 603 MHz 693 MHz 747 MHz Tap Pre-Fault 7839 Southold X9C103 Spliced Point: Ground Block: Tap Post-Fault Aerial work(list pole-numbers)&,- nearestthousenumbe s TYPE POLE HOUSE# LockBox�.'",_. -'�i'Box CoverNeeds RopleceinenL^",,� 'Vaults - ; •Pedestals_ Is there a TEMP cable in place at this time? YES Flo 80 Does the repair require a ROAD CUT? YES Fig 375 DRIVEWAY SHOT F YES #OFDRIVEWAYSI 1 CONSTRUCTION TYPE UNDERGROUND CABLE TYPE: 650 NIC2 FOOTAGE 375 Depth Is this a house drop? NO What is the drop length9 Is there a spare cable') NO Is the drop Aerial or U/G? Underground YES Cable broken from the output of the 10 tap on the comer Fittings and equip.been changed? of Main Rd and Crownland Lane.Down the riser pole 496,to the Input of the Minibridger on the opposite side Comments-of the road(375 feet 650 MC Cable)near 375 Crownland NO lane.Temp run from riser pole to speed limit sign which Is this a dangerous situation? cut the cable _ SIGNAL LEAKAGE MEASUREMENTS' CLI Level@ 10 feet before repair meas Location and repair of[Oak if above 20uV/m If leak Is generated from plant Identify the approx.location Ho.."T.ILJ Omp Feed., Trunk - of the leak and document of information on this form. C LI Level @ 10 feet after repair meas. Pad Value(if used) Dispatch V# -- - - - - DESIGMREFERRAL• t- All design referrals must have takeoff poles and foots es Drawing must have exact location of cable drops and feeder if needed Third Party Damage Information Tech# Time worked 1st Tech 2229 3 hours 2nd Tech 2276 1 Hour 3rd Tech ` ttached ire Spa 5 (Construction Use Only) Date Received:_ Tech(s)/Contractor assigned to:, Date'Assigned:, •NCR-(not const related)-;'c "'"' NCR=GivemBack To; — ;NCR--Da te GiverrBack: _ ,,Actuat Comp.Date: ='r, Tech(s)'/Contractor who completed the,infork ;;Corripletion Code Construction Completion Comments: Needs Activation YIN 'NCR requires comment `