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Home My WebLink About185, 210 Shore Ln q- boo Permit No. Blq 14 TOWN HIGHWAOY DEOUTHOLD FF DEPARTMENT Peconic Lane Peconic,New York J1958 oy (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 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. JGe-S (Jr)6e N i(l0W1 G (k)14-i e-5 ! G - �7r- rivL- Name of Applicant Phone Number Address of Applicant 2. �oe - Fs 62adl Oto rid-dUgi rte-/. Name of Contractor Phone Number Address of Contractor 3. "1 P, Name of Property Owner Requesting Service(if applicable) Address of Owner 4. 165.E-91U -s6g In %Jr4ldie,o A-Iec/- -0ee-valG - yrlaer 9-,-4-rm45s) le /X�yv gac - 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. 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: Completion Date: 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation ob�(L Must be provided Backfill&Completion for consideration as a Pavement Replacement L. t.1,1..1 n eVJ W 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: D-39 1 of 3 1 Insurance Coverage:(Attach Copy) nn (a) Insurance Company: (b) Policy#: 36-0 , 2Co f EJ TJ�JOtill IoY1 acid- (c) �� (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. ck /Service Connections excavations @$50.00 $ V (J 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$ " "~ '� �✓ 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 Excavation permit to: accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(ify)attached he oJY SUPERINTE NT TOWN OF S 7 C Vi cent Orlando Z / ^ Date Date Received by the Town Clerk p` Date Permit Issued D\l a\ b Permit No. 1311, 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 qr (5/3 mod c4 r\ necLn Fe ccln ,L 9S � 0 uCR-�1l-1 ► �f �c) I$S -vnJer v l-� ,l��a 02 /U �,,� 60 ;f �s-�l �1 -8 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 GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. 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 permit,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 Richt to Trespass or Interfere with Private Property Rights: 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, or interest in real or personal property held or vested in a person not a party to the permit. 3. Protection of the HiLyhwav 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 immediately 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& Comnaction 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 Scone 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(1001 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). I Feb. 7. 2020 2:18PM !' No. 1731 P. 1 • a NYSIFb ntaw vne4 state Insurance Fund 6 CORPORATE CENTER DR,SRO FLR,MELVILLE,NEW YORK 11747~3129 i_ nyslfi aom CERTIFICATE OF WOR ERS'COMPENSATION INSURANCE "AAAAA 331212677 SPECIALIZED INSURANC9$ SERVICES INC 204 ROUTE 112 PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JOBS UNDERGROUND UTILITIES INC TOWN OF SQU7HOLD 8 GULL DIP ROAD .53095 ROUT'S 25 RID09—NY 11981 PQ BOX 1179 j SOUTHOLD NY 14968 a POLICY NUMBER CERTIFICATE NUMEE POLICY PERIOD DATE FUST 309-2 223711 08/1012019 TO 08/1012020 2/7/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER h AMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO, 2157309-2, COVE,ING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW (YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EX �PT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDEI'S REGULAR NEW`PORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARD 40 SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WE ISITE AT HTTPS:AWWW.NYSIP.COWCERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN I HE EVENT OF FAILURE T4 GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS I ARISE FROM SOMLY INJURY SUFFERED BY THE OFFICERS OF THE INSURER CORPORATION, JOSEPH ROBSON(PRES)OF DOES UNDERGROUND UTILITIES INC (ONE PERSON CORP) �j THIS CERTIFICATE IS ISSUED AS A MATTER 04 INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICA1'9 HOLDS L THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ASTER THE COVERAGE AFFORDED BY THE POLICY. I i { { t NFW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER,240808638 U26.3 May 01 1911:36a Bay Harbour 6312892176 p.2 '`10k ' CERTIFICATE OF LIABILITY INSURANCE Dncinj.)' 19 osra1r2o1s 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: 0 the certHicate holder Is an ADDITIONAL INSURED,the policy(les)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 endorsement. A statement on this certificate does not confer r1gipts to the certificate holder in lieu of such endorsement s). PRODUCER CONTACT John C Barry Bay Harbour Ins Agency, Inc. PHONE FAx 88 Waverly Avenue -1�INLr l cq:- (639)758-1550 00 N,,(G 1)2139-2176 Patchogue,NY 11772 ADDRESS: Jban,§l ayharbourgroup.corn INSURER S AFFORD)NG COVERAGE MAIC 9 IASURED IKSURERA: -Ev?n aW Ins WatlCp Comp n msuRERB: En uranc_e_American Insurance 41 18 Joes Underground Utilities Inc INSURERC: 8 Gull Dip Road INSURERD: Ridge, NY 11961 INSURERE: W SURER F COVERAGES CERTIFICATE NUMBER: 00000000307651 REVISION NUMBER: 2 THIS IS TO CERTIFY THAT THE PCLIGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE=OR THE POLIC"PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMEN- TERM OR CONDITION OFANYCONTRACT OR OTHER DOCUMENT YNTH RESPECT TC W;iICH THIS CERTIFICA-E MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY-HE POLICIES D=SCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUS ONS AND CONDITIONS OF SLC-POLICIES.LIMITS SHCWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SU8 LTR TYPEOFINSURANCE POLICY NUMBER fPddONDI D ICY EFF MPmmp EXP LIMITS A X CRM►tERCIAL GENERAL UAe1LITY Y N3EQ3321i 11412912019 ON2912020 EACH OCCURRENCE S 1,000.000 \CLAIMS-MADE ^J OCCURI A E"M-RSD PREWSES,Eao.:G.rrence) S 10.000 VED EXP(Any ore person) t 5,000 =ERSCNALaACVIAJLIRY = 2000000 GEN'LAGGREGATE UMITAPPUESPER GENERA-AGGREGATE S 4,Q0o0Oa X,POLICY 1 PRO- L—JECT 7 LOC PRCDLICTS-COA1PAOPAGG 1 5 4,000,000 OTHEP. S AUTOMOBILE UABIUTY COMBINED SINGLE LIMI- 'S Ea acddent} --ANY AUTO ' BODILY INJURY IPer person'. $ OVVNED SCHEDULED -AUTOS ONLY AUTOS BODILY INUURYiPeracadeni) S HIRED NC"VVNED Y DA6tAGE PERT AUTOS ONLY AUTOS ONLY Per PROPERT accident) $ i S BurABRELLAUAB X OCCUR I ELD30000649000 04/2912099 04/29/2020 EACHOCCURRENCE S 5,000,000 X EXCESS LIAR CAWS-MADE AGGREGATE S 55,000,000 DED I RETENTIONS i WORKERS CONDENSATION 'i PER GTH- ANDEMPLOYEWUA6ILJTY YIN STI;TUT- E ER ANY PROPRIETOR/P,,RTNERIEXECUTIVE p OFFICER.MEMBER eZLUDED? ❑ MIA A EL EACH ACCIDENT (Mandatory d ery Ix,u-d E.L.DISEASE-Et..EMPLOYEE S 11 yes.descr�m u?der DESCRIPnON OF CPERATIONS below E.L.DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONSILOCATIONS VEHICLES IACORD-101.AddiflowI Remarks Schcdulo,may be attached d more space Is required) Certificate Holder is included as additional insured as per written contract. RepairlReplace CATV lines for Cablevision. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DE:SCRISED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Po Box 1179 Southold,NY 11958 AUTHDR2EDTREPSM�TATp,,E (JCB) m 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2D16103) The ACORD name and logo are registered marks of ACORD Pnnted by JCB an May 01,2019 at 11:34AM May. 1. 2019 11:04AM Specialized Insurance No. 3289 P. 2 Workers' CERTIFICATE Of INSURANCE COVERAGE - Eqaco mpeasatton �wpd DISABIUTY AND PAID FAMILY LEAVE BENEFITS LAW PART L To be completed by Disability and Paid Family Leave Benefits Carrier or lit eased Insurance Agent of that Carrier is,.Legal Name b Addwa of Insured(use sbeet address only) IN Business Telephone Numberof Inwm4 JOIFS UNDERGROUND UTILITIES INC 631-48"512 8 GULL DIP ROAD RtOk3E.NY 99961 9m Federal Employer Idea icatfon Number of Insured cdtaFebaaltwih NewYor&Srare,is,.Wrrp4p FWah 2 Nemo end Address of Entity R MussHng Woof of Coverage 3a.Name of insumnw Canter (Entity Being Listed as the Corgeate Holdar) sheiterPolnt Life Insurance Company TOWN OF SOUTHOLD 3b.Policy Number of Erift timed In Box'1a' 53095 ROUTE 25 DBL260677 PO BOX 1179 3o.Po ft elftIve period SOUTHOLD NY, 11958 09IM2018 to 091211=0 r 4.Pd1W praWdes the foltaov Rg W013: ® A.Both dlsabiiity and patd famlgr two beneft B.D1sabUHybenefltaonty. Q Pald family leave beneft only. severe; ® A.AD d rho employer's emptoyees el4lwa under the NYS OlsaNlyand Paid Fm*Leave Beneflts Law. %Oniythe rotlowing class ordasses of emplo}rer's employees: Hader pmay of pens^I toffy that I am an auiho r6pmW—ftUV9 or hoensed ager of the nstuance cA re d BMW and that(he named Insured has NYS DlsabDlty andfor PNd Fav*Lem 8oneRm WuraAce coverage as described above. Date Signed 5/1/2019 BY �W tStgnsluw olGrturafwe carders autttorhedmpmentatlaeot tfiiSUeerrsedtnruranreAsentoRlmtGuumacecmrrgt} TeDephoneNumber b16-829-8100 Nam and we Richard Whits CltlBf EX6clttiye Officer IMPORTANT. If Boxes 4A and SA are c1mciked,and dris fiorm Issigned bythe insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carder,Oft certificate is COMPLETE.Mall It d)redly to the cerDf icate holder. If Box 4B,4C or 50 Is dwaked,this Certificate Is NOT COMPLEM for purposes of Sealton 220,Subd.8 of the NYS Dlsablilty and Pald Famity Leave Beneflfs Lew.It must be mailed forcomptattan to the Workers'Compensation Board.Piens Acceptance Uhlt,I O Box 5200,oinghamunk Mr 13902.000. PART 2.To be completed by the NYS Wor'kers'Compensation Board(only 9 Box 4CorSo of Part i has been checked) State of New York Workers'Compensation Board According to bftffnaDon mainlalned by the NYS Workers'ComperMIlon Board,the above-named employer has compiled m4h the NYS Disab ft and Paid Family leave BenaTtts Lour with respect to all of his/her employees. Date stoned Ry (ftsU Rot AuftMW WVVor1efCC0nWr 0*n Board KnVlgw) Telephone Number Rama end THte Please Nom-k*inswame catrions howwdtowrQe NYSdbWftyandpaNW*jemre hffaft Murewpalldesand M/S fk~howl ce sWis of those lnaurance confers are euthodked fo!sero Farm M120 f.fns mmohmkrers we NOT auffwraed to!esus,We tams DID-1zoi (1g-1>> ii IIIIIllfi111��pp1l881�Ni�li�l� �I us-120.1 (10-17)