HomeMy WebLinkAbout1340 Kimberly Ln Permit No.—A 43 3
TOWN OF SOUTHOLDoogvF>Q�o�
HIGHWAY DEPARTMENT
Peconic Lane o
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
pin suant 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 Permif'and"Special Conditions",if any and to permit authorized
inspectors to make necessary inspections of the job site.
Print or Type r / /
b3l - W-7-23z� _Jo o�inSon �/r 7i•�1•� c P/�
Name o Applicant' Phone Number Address of Applicant
2. u r �lt�;i, .�w�. �-�I-49 -237-1
Name of Contr. for Phone Number Address of Contractor
3.
Name of Property (Owner Requesting Service(if applicable) p Address of Owner
4. 1'1L�,ati�a darnat ,=A QRT" J ^�¢e def to 'lYvn� at 13qo K1,MJ v 4 LA,� s. bIA ) Oycth is ZeXnnnA 1.+,
Workbes p on 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 pplicant
Application/Permit Form is
Required for a complete application! 9-22 - 20 Zd
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:
S. 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:
(b) Policy#: 3LS Go(,p5'�5 tO
(c)State whether policy of certification on file with the Highway Department: 1.1
(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 $ e
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 a $1,000.00/Each $
No.
Additional Repairs of Same Service @$500.00/Each $
No.
TOTAL$ �T v 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 Excava 'on permit to:
in ccordance with
this application and subject to the"General Conditions"and"Special Conditions"ofpermit(if any attache ereto.
SUPERINTEND OF G
TOWN OF SO OL
VigEent M.Date; ��((��
02"
Date Received by the Town Clerk 6
Date Permit Issued (I166 Permit No. 'j 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
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Copy Distribution: 2
Permit# 7
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1A
2nd
3rd
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 5
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 Hi$!hway 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. Storaee 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.
D-39 4 of 5
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).
Revised: February 2018
D-39 5 of 5
CERTIFICATE OF LIABILITY INSURANCE DATE(M 9/29/2A0
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: It the certificate holder is an ADDITIONAL INSURED,the pollcy(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 rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
SPECIALIZED INSURANCE&SERVICES PHONE - FAX -
204 RTE. 112 A/c
PATCHOGUE,NY E-MAIL
11772 ADD ESS: SRU SPECIALIZEDINSURANCE.COM
Auto-Home-Business-cycle-etc. INSURERS AFFORDING COVERAGE NAIC#
-------— INSURER A,LIBERTY MUTUAL INS.CO. 36447
INSURED
AMT UNDERGROUND UTILITIES INC INSURER B:
INSURER C
10 JOHNSON ST INSURERD:
PATCHOGUE,NY 11772 INSURER E:
INSURER 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 BY PAID CLAIMS.
1NSR ADD SUB
LTR TYPE OF INSURANCE POLICY EFF POLICY EXP
POLICY NUMBER
t D Y MIDD Y LIMITS
COMMERCIAL GENERAL LIABILITY BLS60605638 EACH OCCURRENCE $ 1,000,000
A Y N 11/29/2019 11/29/2020 '
CLAIMS-MADE OCCUR REAI ES(Ea occurroncel 300,000
MED EXP(Anyoneperson) $ 15,000
} PERSONAL&ADV INJURY $ 11,0001000
GEN'LAGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000
POLICY Pq
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PRODUCTS-COMP/OP AGG $ 24()0.000
OTHER: $ o
AUTOMOBILE LIABILITY COMIBIIIE1181NGLCUMIT $
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ANY AUTO (FA
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AUTOS CNLY AUTOS BODILY INJURY(Per accident)SCHEDULED S
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AUTOS ONLY AUTOS ONLY PeIdS
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MAGE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER DTH- '
AND EMPLOYERS'LIABILITY Y I N
1.ANY PROPRiETOR/PARTNER/EXECUTIVE
OFFIOERIMEMBEREXCLUDED? NIA E.L EACHACCIDENT $
(Mandatary In and EL DISEASE-EA EMPLOYE $
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DESsCRIPTION OF OPERATIONS below E.L.DISEASE.POLICY LIMIT $
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DESCRIPTION OF OPERATIONS/LOCATIONS i VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached It more spacols required)
CONDUIT CONSTRUCTION
CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED AS REQUIRED BY WRITTEN CONTRACT/AGGREEMENT
CERTIFICATE HOLDER CANCELLATION
TOWN OF SOUTHOLD SHOULD ANY OF E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PECONIC LANE THE EXPIRAT DATE THEREOF NOTICE WILL BE DELIVERED IN
PECONIC NY 11958 ACCORDAN N T E POLICY P ISIONS.
AUTHORIZEMESE A
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD
e
NySllF
New York state Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129
nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
^A^A A A 823217426
PAUL E BELLINI CPA
521 ROUTE 111 UNIT 310 ' f
HAUPPAUGE NY 11788
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
AMT UNDERGROUND UTILITIES INC TOWN'OF SOUTHOLD
10 JOHNSON ST 631-765-3140
PATCHOGUE NY 11772 PECONIC LANE
PECONIC NY 11958
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
12431382-7 554580 11/13/2019 TO 11/13/2020 9/22/2020
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2431382-7, COVERING 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, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY
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MIGUEL TURCIOS
TREASURER
DAVID TURCIOS
AMT UNDERGROUND UTILITIES INC
(TWO PERSON CORP)
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NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:79893868
U-26.3