Loading...
HomeMy WebLinkAbout425 Summit Ln 3 �a Zs Permit No. l TOWN OF SOUTHOLD 4y1 FWtIr HIGHWAY DEPARTMENT Peconic Lane ? Peconic,New York 11958 o '* (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. �U�S l)nc�;yc►►�cyr U��� �-��S �U� Oub(-eV f 51 Gn Name of Applicant Phone Number Address of Applicant 2. �Ce- R-db5or-s 631-q�y X51� - a 60,/ 01,P act -kiJoe NS - 1I ICS/ Name of Contractor Phone Number Address of Contractor LJ 3. N 1 Name of Property Owner Requesting Service(if applicable) Address of Owner S i-nRf'I nGt 4. �j-Q(J\au— C 4L) I (n.eS be-Fween ya Zr SIS- Suw,r.,t(+ Lr) - L. Manan 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: Ipp"C i o G► Pew 14 13 a/S Completion Date: , o&Me- �Gtc 8. Work Schedule: Phase Completion Date Excavation SGryxg— ZAS./ 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: UA-A S 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: (_UG a5k-J v � S CU �fhciur,-"cy- Cc,n `LKS' (b) Policy#: -L-Q — e Q r)?CYJr10(y%aCZo (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 r , 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 Superiinntendent. Al. /Service Connections excavations @$50.00 $ 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$ v� 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 Excavati permit to: in a cordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any) ttached hereto. SUPERINTENDE OF S TOWN OF SOUT OL Y V1 n-cenf M.6K ndo ZIP zo Date Received by the Town Clerk �� o`Za as Date Date Permit Issued �I 1�(�0 aQ Permit No. 13 O 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 � S3�3c>Z psi 3� Ll 0�S-, S,i 57 Sur ry-)i Ln C/5 `, --,Cr(nc, Ln as 4- /0 S A -L) O AC'Y'-� \ uc� 1-4- an CG-� sly' )f Py-� x'70 r r c-` I m G t G` (tel � S 32� Copy Distribution: o 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/PERNIIT 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 Highwav 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& 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. 1. 2019 11:04AM1 Specialized Insurance No. 3289 P. 2 YO K Workers' CERTIFICATE OF INSURANCE COVERAGE - THE 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 8 Address of Insured(use street address only) J ib.Business Telephone Number-of Insured JOE'S UNDERGROUND UTILITIES INC 631-484-8512 8'OULL DIP ROAD RIDGE,NY 11961 ic, 2.Name and Address of Entity Requesling Proof of Coverage 3a.Name of insurance Carrier (EntilyBeing Listed as the Cerilficata Holder) ShelterpointLife Insurance Company TOWN OF SOUTHOLD 3b.Policy Number of Entity Listed to Box°1a" 53095 ROUTE 25 DB1260677 PO BOX 1179 3c.Policy effective period SOUTHOLD NY, 11958 09!221201$ to 09121/2020 4. Paltry provides the following benefiils'. © A.Both disability and paid family leave benefits. 0 B.Disability benefits only. C Paid family leave benefits only, 5. Policy rovers: ® A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B,Only the following class or classes of employers employees: Under penalty of perjury,I certify that I am an sulhodzed representative or licensed agent of the insurance carrier referenced abovaand that the named insured has NYS Disability and/or Paid Family Leave Benefits irlstrraAW coverage as descnW above. Date signed 5/1/2019 Ely (Stgnatum of insurance carders authorized repmentauue or NYS licensed insurance Agent ofthat rnsurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this farm is signed by the insuranto carnet's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 48,4C or 5B is checked,Vila certificate Is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Famlly Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Aomptahce Uhl[,PO Box 6200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4C or 96 of Part:i has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has compiled with the NYS Disability and Paid Family leave Benefits Law with respect to all of his/her employees. Date Signed By (signature of Authorized NYS WarkWComoensatran aoard Employee) Telephone Number Name and Tills Please Note.Onty lnsdranee carriers Acehaed to write NYS drsabrlityand paid tamt/yleave benefits insurance pelhfes and NYS licensed Insurance agents of those insurance centers are authod/zed to issue Form Da-120.1.Insurance brokers are AID T auf horized to issue this form. D13.120.1 (10.17) Il��l�lllll�l� il�ldlllilll��lliq�l(IIIII��� DH 120.1 (10-17) Feb. 7. 2020 2:18PM No. 1731 P. 1 NYSIF stew vark state Insurance Fund B CORPORATE CENTER DR.3RD FLR,MELVILLE,NEW YORK 11747.3128 i. 1 nySlfc®m CERTIFICATE OF WOR K SRS'COMPENSATION INSURANCE PIN r'AAAAAA 331212677SPEC(ALIZED INSURANCE A SERVICES INC 204 ROUTE 112 PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER i CERTIFICATE HOLDER JOSS UNDERGROUND UTILITIES INC TOWN OF SOUTHOLD 8 GULL DIP ROAD 53096 ROUTE 25 RIDGE NY 11961 PO BOX 1179 80UTHOLO NY 11968 POLICY NUMBER CERTIFICATE NUMBE POLICY PERIOD DATE 12157309-2 222711 08/10/2019 TO 08110/2020 217/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER P i ED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO, 2157 309.2, COVE ING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW !YORK WORKERS' COMPENSATION LAW NTH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXC SPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATION$ OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU W►SH TO RECEIVE NOTIFICATIONS REGARD�G SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WE BSITE AT HTTPS:/~.NYSIP.COWCERT/CERTVAL.ASP.THE NEW YORK .STATE INSURANCE FUND IS NOT LIABLE IN rHE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION, JOSEPH ROBSON(PRBS)OF JOES UNDERGROUND UTILITI$�S INC (ONE PERSON CORP) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLD90t. THIS CERTIFICATE DOES NOT AMEND. EkTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. l I 1 NSW YORK STATE INSURANCE FUND } DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:240805638 U ZB.B May 01 1911:36a Bay Harbour 6312892176 p.2 A��Dom® CERTIFICATE OF LIABILITY0ATE 5101 INSURANCE D05/01 DDlY/2019 9 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 pDllcy(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 endorsomenL 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. PHONE FAX- 88 Waverly Avenue euA�IL�a;tr (631J768-1650tAlC No. s31 2e9-2tts Patchogue,NY 11772 ADDRESS- Jban(Rbayharbour rcrooup.com INSUR S AFFORDING COVERAGE NAIC x tNsuRERA: EVaut_Q. Insuf�OCE��IP—��r 3rJ3 INSURED msuRER6: American Insulance 4� 1g Joes Underground Utilities Inc INSURERC: En ranee 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 PCLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE=OR THE POUC"PERIOD INDICATED. NOT1APITHSTANDIN(3 ANY REOUIREMEN- TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT IMTH 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 SHCVVN MA"HAVE BEEN REDUCED BY PAID CLAIMS. IRR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP POLICY NUMBERtYfNOD MM.'D UTAnS A X COMMERCIAL GENERAL LIABILITY Y N 3EQ3326 0412smo19 04/29/2020 EACH OCCURRENCE S 1 000.000 CdAM-MADEn i OCCURMA EYr01 BED EeENIMESiEaoxt.rreM-0 S 10000 VED EXP any ore person) 1 5 000 =E SoNAL a ACV II.JURY 1 2,000,000 GEN'LAGGREGATELIMIT APPLIES PER X r POLICY_,PRO- GEt GP. ERn_AGEGSTE S 4,000 000 OT ER. _ ��JECT LOC PRODUCTS-COMPlOPAGG s 4,000,000 S AUTOYOBILEUABLUTY COMBINEDSINGLELwr S AN AUTO jEa achdent} OYvTED SCHEDULED BODILY INJURY tPer person) S _ -AUrOS ONLY AIJrOS BODILY INJURY(Peracadeni) S HIREDED AUTIO AUTOSNC" NLY PROPERTYDAhtAGE AUrOSONLY AUTOS ONLY Peraccideni S i S E B XAX OCCUR ' ELD30000649000 04129/2019 04/29/2020 EACH OCCURRENCE S 5,000,000 XEXCESSCESS UABB CAWS-MADE AGGREGATE S 55,000,000 i DED RETEJJTIZ-NS WORKERS CONDENSATION i AND EMPLOYERS,LIABILITY YIN STATUT= EORTH- ANY PER30FM B R FXCLUDEO?ECUTIVE EL EACH ACCIDENT g (Mandatary in NH)ECCLUDED7 7 N/A (Maneatary in NH] ]IyrMdesabeuMer ELDISEASE-EAEAAPLOYEE S DESCRIFTrNOFCPERATIONSbelow E.L.DISEASE-POLICY WAIT S t DESCRIPTION OF OPERA'n0NS 1 LOCATIONS 1 VEHICLES iACORD 101,Additional Remarks Schedule,may Ira 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 DESCRIBED 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 11968 ADTHawzeDREP sENTArnE JCB m 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Pnnted by JCB on May 91,2019 at 11:34AM