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TOWN OF SOUTHOLD vis%004
HIGHWAY DEPARTMENT
Peconic Lane ti
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Peconic,New York 11958 90 Yr
(631)765-3140 Ado!
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.
Name of Applicant Phone Number Address of Applicant
2. ��co- 1 �tiY� (03l-�l�s�/ &71) �s Gc�l nOZ�- RJdew- 1�1- 11�la/
Name of Contractor Phone Number Address of Contractor
3. N k Pr
Name of Property Owner Requesting Service(if applicable) Address of Owner r
4. N I NS lel �� IJ�.2` �CYJl1 aUIQc./ /�i/�' Ic�— 9✓CCCiYIiiG – YVl-ISSI le 9-r�U., PG- 4--e, clC CJ#-
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 Z Signature of Applicant
Application/Permit Form is I �a
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 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: [ �5 `� i/�S �.el i C/►�y neQ c �a�S
(b) Policy#: -2 ��/1�C,Y)CJ- 6�/9 ow
(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: ✓7 _
Basic Application Fee for Each Project Location - $500.00 X
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 Superin/t�e-nndent.
OTAl. /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:
accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if y)attached hereto
SUPERINTEND NT S
TOWN OF S TH ,
Vi cent NT Orla do
al cn� ^ Date c9 2,6Zu
Date Received by the Town Clerk 0� ��o"�
Date Permit Issued ) l(I\U-,o Permit No. M3
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#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1st
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
W1P 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 Right 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 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 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 (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).
Feb. 7. 2020 2: 18PM No. 1731 P. 1
NYSIF
New York state Insurance Fund 8 CORPORATE CENTER DR.3RD FLR,MELVILLE,NEW YORK 11747.3129
I nySlf.Com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
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n A A A A A 331212677
SPECIALIZED INSURANCE&
SERVICES INC
204 ROUTE 112
PATCHOGUE NY 11772 SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
JOSS UNDERGROUND UTILITIES INC TOWN OF SOUTHOL0
8 GULL DIP ROAD ,53095 ROUTE 25
R113GE NY 11961 PO BOX 1179
SOUTHOLD NY 11958
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
12157309-2 222711 06110/2019 TO 0811012020 21112020
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY N0, 2157 309.2, COVERING THE ENTIRC 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, 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 WE$SITE AT HTTPSJMMNW.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 COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED 13Y THE OFFICERS OF THE
INSURED CORPORATION.
JOSEPH ROSSON(PRES)OF
JOES UNDERGROUND UTILITIES INC
(ONE PERSON CORP)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICAT5 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:240805638
U•26.3
May 01 1911:36a Bay Harbour 6312892176 p 2
A R ATE CERTIFICATE OF LIABILITY INSURANCE 005/01"'°°"
05/Q11'2019
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 certHlcate holder Is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain polldes may require an endorsement. A statement On
this Certificate does not confer ri hts to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
Bay Harbour Ins Agency, Inc. PHONE Jahn C Barry FAX
� yy fir_ (631)758-1550 lArc,�1.;631 289-2176
88 Waverly Avenue ,;MAIL Jbarry@bayhartiourgroup.com
Patchogue,NY 11772 INSURERS AFFORDING COVERAGE
- NAIc><
INSURED '
INSURERA: Eva 1^ILQn InsuM 13C1P Com n 38_
INsuRERB: Encl.Mraae American InsuJdnce 47 1Z8
Joes Underground utilities Inc INSURERC:
8 Gull Dip Road INSURERD:
Ridge, NY 11961 INSURER E:
WSURER F
COVERAGES CERTIFICATE NUMBER: 00000000307651 REVISION NUMBER: 2
THIS IS TO CERTIFY THAT THE PCLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEb ABOVE=0R THE POLIC`r PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT'MTH RESPECT TC WHICH THIS
CERTIFICA-E MAY BE ISSUED OR Ib1AY PERTAIN,THE INSURANCE AFFORDED BY-HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUS ONS AND CONDITIONS OF SIC-'POLICIES.LIMITS SHCWN MA's HAVE BEEN REDUCED BY PAID CLAIMS.
INI'R TYPE OF INSURANCE ADDL SUB POU 710
POUCYNUMBER umLIMIT'S
A LTR' x COMMERCIAL GENERAL LIABILITY Y N 3EQ3326 04/29occu $ 1 D00 000
CLAIRtS-MADE OCGl13 IES�FAoccr.rroS _ 10.000
EXP An ore person) 1 5 000
ONAL E ACV INJURY f 2 000 000
GEN1-r.GGREGATEU)drrAPPLIESPER. RA_AGGP,EG4TE 5 4.000 000
X,POLICY PF.O� ,JECT LOCUCTS-COMPIOPAGG 5 4,000,000
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AUTOMOBILE LIABILITY
OCOMBINED SINGLE LIMP S
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ANY O SCHEDULEDBODILYIWWYMer perseW. S
OWNED
-AUrOS ONLY AUTOS BODILY IWURY(Peracadeni) S
HIRED NC"VVNED PROPERTY DANtAGE
Aln'OS ONLY AUTOS ONLY Per PERT n $
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B UUBRELLAUAG X OCCUR ' ELD30NO649000 04/2912019 04/29/2020 EACHOCCURRENCE S 5,000,000
X EXCESS UAa C.AIMS-MADE AGGREGATE s 5,000,000
i DED RET04TI:05
WORKERS COMPENSATION
'ANDEMPLOYEWLJABJUTY YJN PER DTH-
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ANY PTOR/ LEXECUSTATUr_
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OFFICSUIEM632 EXCLUDED? TIVE � NIA E.L.E4CH ACCIOENT S
(Mandatory mNH) EL DISEASE-EA EMPLOYEE S
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OESCRIFrtCN OF OPERATIONS below EL DISEASE-POLICY LIMIT 3
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DESCRIPTION OF OPERAT7ONS I LOCATIONS 7 VEHICLES IACORD 101,AdrLltcm I Remarks SchcdWo,may be attached d more space Is requlmd)
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 WITH THE POLICY PROVISIONS.
Po Box 1179
Southold,NY 11968 AUTHORIZED REP TATIVE
JCB
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