HomeMy WebLinkAbout1780 Village Ln Permit No. Isso
TOWN OF SOUTHOLD ,y gpFPO��-
HIGHWAY DEPARTMENT �,��� ooGy
Peconic Lane
Peconic,New York 11958 y
(631)765-3140 '�'ol
APPLICATION/PERMrF 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 Tyne
1. ,�S (»fD�d UMJI.65 (�Jr (UablgcAS!O;. —
Name of Applicant Phone Number Address of Applicant
2. �y� (RCk5,�pon &,S i-y S-q-mss/ - sa Call Dry fZd -OZ &19
Name of Contractor Phone Number Address of Contractor
3. f--�
Name of Property Owner Requesting Service(if applicable) Address of Owner P Ole— V-) e.GK-- -a �cK of�nu�
a. 9780 Ul ItHe Ln Ys �e�G�,�✓ 5� - Urie�-I- PO1n4- Fr f
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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.
1
NOTE: All information requested by this Signature of Applicant
Application/Permit Form is
Required for a complete application! — s-
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 Ffiighway 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 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:
D-39 1 of 3
12. Insurance Coverage:(Attach Copy)
(a) Insurance Company: L0dY'\S6m J—,n S C 2Cali eg A w-gljdca 17 :Kati�
(b) Policy#: ECJ �33-)-6 1 I �C/C-10 J f 9 000
(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. J�. /Service Connections excavations @$50.00 $ / �L�%►(,�
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:
in accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if y)attached hereto.
SUPERINTELNTTOWN OF SOM"t
Vi ent M.Orlando
Date
Date Received by the Town Clerk a I a�o��
Date Permit Issued 41(ablb Permit No. t�Q
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
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Copy Distribution:
Permit# 1 3 g.Q)
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
ist
2nd
3`d
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
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 Hizhway and Future HiEhway 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& 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(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).
May 01.19 1 1:36a Bay Harbour 6312892176 p.2
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CERTIFICATE OF LIABILITY INSURANCE D 05101/22019019M1Y)
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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: If the certificate holder is an ADDITIONAL INSURED,the poflcy(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 endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
Bay Harbour Ins Agency, Inc. PHE John C Barry
FAx
88 Waverly Avenue EM`t ALS ex,,-. (630758-1550
Patchogue,NY 11772 ADDREss Jbarry(Abayharbourgroup.com
INSURERS AFFORDING COVERAGE NAIL 9
IASURED IMsuRERA: Ev�n�Q. nS_W''a13-C Company -36a78_
wsuwts: En uranee-A- eri an Insurance 41 18
Joes Underground Utilities Inc INSURERC:
8 Gull Dip Road INSURERD;
Ridge, NY 11961 INSURERE;
INSURER F:
COVERAGES CERTIFICATE NUMBER: 00000000-307651 REVISION NUMBER: 2
THIS IS TO CERTIFY THAT THE PCLIGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE=0R THE POLIC"PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMEN-,TERM OR CONDITION OFANYCONTRACT OR OTHER DOCUMENT'NTH RESPECT TC WHICH THIS
CERTIFICA-E MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY-HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUS ONS AND CONDITIONS OF SUC-POLICIES.LIMITS SHCVVN MA"HAVE BEEN REDUCED BY PAID CLAIMS.
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DESCRIPTION OF OPERATIONS f LOCATIONS!VEHICLES(ACORD 101,Addi'lonal Remarks SchedWe,may be attached d more space Is required)
Certificate Holder is included as additional insured as per written contract.
Repair/Replace CAT/lines for Cablevision.
CERTIFICATE HOLDER CANCELLATION
Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE MILL BE DELIVERED IN
53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS.
Po Box 1179
Southold,NY 11968 AUnMDRIZEDREP SWTATtVE
JCB
O 1988 20'15 ACOi2D CORPORATION. All rights reserved,
ACORD 25(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
work' CERTIFICATE OF INSURANCE COVERAGE -
qajioamard
nsation DISAINUTY AND PAID FAMILY LEAVE BENEATS LAW
PART:1.To be completed by Disability and Paid Family leave Benefits Carrier or Utmed Inwrance Agent of that Carrier
la.Lagat Name 8 Addmw of Insured(use street addreas only) A Business Telephone Numborof Irmfed
JOE'S UNDERGROUND UTILITIES INC 631484-8592
8 GULL DIP ROAD
tilDCiE.NY 11969
1c.Fedeml EaVoyer Ideniifrcadon Humber of Insured
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2.Name w d Address of Enuty Reque3kg Famf of Caverage ee.Name of insumnoa Canier
(Entity Being Usted as the CerUnoale Halder) ShelterPolnt Life insurance,Company
TOWN OF SOUTHOLD Policy Number of EMh►Listed In Box'1a'
53095 ROUTE 25 13131.260677
PO BOX 1179 XPefteffectivepedod
SOUTHOLD NY, 11958 =22f2018 w 08129f2020
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Ueda pe pa4ury,resiffy that I am on mutarva rep or lidensed ApMof the Insumce canlerrarwatmd above artd that the named
insured bas NYS usability and►or Patd Family Leave BenaAts Wur4w caveWge as described alb e.
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Licensed Insurance Agent of(fret carder.this ce 0c ate Is COMPLETE.Mall It directly to the certificate holder_
if Box 48.4C or 58 Is cttedced,this cettif eaW Is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYE
Dls Oly and Pald Rmtty Leavy Benet Law it must he mailed for completion to the Workers'Compensagon
Board,Plans Aweptahoe UrA PO Box 5204,Binghamton,NY 93902-200.
PART 2.To be completed by the NYS Worltere Compensation Board(Only BBox 40or Se of aa:t i has been rhed,md)
State of New York
Workers'Compensation Board
Awarding to informstinn maintained by the NYS Wot9c W Compensation Board,the above-named employer has compiled wUh the
NYS Disability and Paid Family Leave Benefits Lavin With respeot to ilii of hialher employees.
Date Signed By
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