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HomeMy WebLinkAbout1350 Bayshore Rd Permit-No. til, TOWN OF SOUTHOLD � ...- IRCrIWAY DEPARTMENT Peconic Lane ' Peconic,New York 1.1958 : (631)765-3140 APPIACATION 4ERMIT'FFR HIGHWAY EXCAVATION AND REPAIR APPLICATI©N I5 BERE13Y made to the Superintendent of Ifighways of the Town.of Southold for the issuance of an Excavation Permit pdrse aritto Chapter 237 of the Code'ofthe Town of Southold,Suffolk County,New York,and other applicable flaws,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 Permir,and."Special Conditions",,if anyzan&to permit authorized inspectors to make necessary inspections,of the job site. Print or-r"Tune � _L 1- 7h,QS I4 hur�Li S/6-�/� Q'e�702 Ad X �.S"G'7 .Jav���rr,�TG�, /y Nam dfApplica t I PhoneNumber Address ofApp�1icant 2- TL-/ 4 L0h4l. 14 SIO'►, ffic .lgme r Tat AAI e Name of Con for -, ' Phone Number Address of Contractor L 3. SG I d re /nCU 4 C Name of Pdperty,Owner Requesting Service(if applicable) Address of Owned' / 4- - Wrrcr 2 � � c /igra ,. & ytG SG tyfrc�e '.� a Work Description and Locatio i(Street Number; e%Cross Street) (a) Is construction located within 75 feet of tidal wetlands? s Yes No X *If yes,other Town permits may be required. NOTE: All information requested by this Signature of plicant Application/Permit Dorm is Required for a complete application! '2/zz l Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed wo& Provide accurate schematic site plan showiiig the location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of all site-wid pavemefif i6st©tation!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 I ighway Excavation Permit by the Town Clerk. 6. Tax Map No.: District 1000 Section Block O 4 . Lot 7. Starting Date: Comipletion Dale: .2„�/a''/ 8. Work Schedule: Phase Completion Date Excavation 2 W©rkschedule Facility Iwstallation doe o Mast be provided . - BackEll.&Completion for consideration as a PaveineFit Replacement Complete Application. 9. Unde which authority is application being made: ' ,�./PA See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified- 10. Estimated Cost-ofPaiiposed,W& 11. Remarks: C6 f s�f I/eK o Ze J4,oef.1Gytdp yh D-39 1 of 3 J2. Insurance Coverage:(Attach Copy) (a) Insurance Company 1-)p .�{SCJ�"a h c Q Cv, Pb Toucy# .-` L'i IR gS ODDS (c)State whether policy of certification on file with:the Highway Department: (d)Coverage required extended to the Town: Any Loss*ludbug Bodily injury,property or commercial injury caused by or attributable to the work performed: .51,00,000 per Occurrence and$2,00@,000 general aggregate. 13. Security:' (a)Surety Bond or Certified Check provided in the total Amount of 5 (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 withimany 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. /Service Connections excavations @$50.00 $ S0,bU 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'm depth and over Total Lineal Footage of Excavation, L.F.@$50.00 $ E. Utility Repair Excavations @$1,000.001 Each $ No. Additional Repairs of Same Service @$500.00/Each $ No. T®TAL$ SS-0.00 F. Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. C4 se 3-'/X G 9 g Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a highway cavation permit to: Highway r ce th this application and subject to the"General Conditions"and"Special Conditions"of permit f any o. SUPE' OF AY TO�]VN OF O LD -YO Vin n E rl do � 1 D Date Received,by°ihe Town Clerk 1 Date)'eimit Issued �((� Permit No. I �� NOT -- 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 Copy Distribution: rr� � � �U Dighway Department Permit# Engineer(with,page 3) Applicant Town Clerk(Original) INSPECTOW S RECORDS Inspection Date Findings(use code) Applicant Notified 1st %nd 3rd th (To Permit Clerk) REIYIAR��S CODE IB Improper Barricades ,11, Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due,to back g) BUC . Building Under Construction WIP Work In Progress ITB 'Improper Backfill(too high,not sufficient) BFS Inspector Holding for Fina!Settlement of Excavation RFR Ready for Repair D-39, 3 of 3 ACC Rte' CERTIFICATE OF LIABILITY INSURANCE 01/14/2021 THIS CERTV"TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND:CONFERS NO RIGEITS UPON THE CERTIFICATE HOLDER THIS CERTWE ATE DOES NOT AFFIRMATNMY OR NEGATIVELY Atli, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MBURER(Sk AUTHORIZED ATIVEOR PRODUCER AND THE CERTIFICATE HOMER. OUPORTANT: Nthe cettilhZte holder Is an ADDITIONAL INSURED,the poticy(ias)must have ADDITIONAL.INSURED provisions or be endorsed. N SUBROGATION N WANED,subject to the terms and conditions of the pcIW certain policies may requite an endorsement: A statement on this certificate does not conferrights,to the certificate hoiden In Hare of such endorse PROVEMER CGUrAM Nate pany MUM- Cgtkftn InSUrance PHONEEft (800)454-1970 2700ErawoodAYe UAUM Fp1c No 388�.r3i I SerY UInft)nft=MnMCOm AFF0R=GC0VE1t=E Mme Roahestat' NY 14618 WSURERA- ERIE INSURANCE CO 26M Ise mm—. FLAGSHIP CITY INSURANCE COMPANY 35585 J S M Lorq Island InQ arserRER c P.O.BOX 2507 wsWREtD: WSURER E: SOUTHAMPTON NY 11989-=7 gpURERF. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A13OVE FOR THE POUCY PERIOD DOMTE IL NGTMTMTAN13ING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VMMH THIS CERTIF[CATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E7(CLUSHM AND CONDrr=S OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, omAW-M TYPEOFOURPANCE L POMYRUAMEt POUCYEFE POLIGYE7CP UNM NMMER ALOERERALLIABIL" EACHOCXlRRENCE $ 1.M0.000 CLASPS rrADE 1 OCCUEi PRHWSES oa m S 1.00 wo R Primary&Ron Cnritrffiutory MED EKP one S 5.000 A X CorrtractualL Y Q48-5950M 1210912020 12/0912021 PemawL&AovINJURY S 1.000.000 GEN'LAGCAWMTEL1WTTAPPL1ESFER: GENERALAGGREGAZE s 2.BEI0.(IQ0 POUCYM� F LOC PRODUCTS-cowioPAGG S 2,000.000 ROTHM S Arff0KO8=UAMVJff $ d SINGLEfJrAIT S 1.000,000 ANYAUTO aODILYINJURYO%rparm) S A r OogrKEDNLY , AMS 012�94001F 1210912020 12/0912021 60ORYINJURY(Pmaac�ent} $ RflRM AOfNO PROPEiiIIIDAVAGE S AUrOSONLY S cSc*a:y LP UrBFp LA LMS IOCCUR EACH OCCURRENCE S 1.000.000 A EXCESSEIAB CLANS-LOME 03&5970028 12/0912020 12/0912021 AGGREGATE $ 1.000,000 77TDEO h REFEMnONS 10.000 I $ TIrORRER3C09PETfBA1= i PER TH � NMEQPCOLUUUff YIN SFA11Ii_ Err B OFF CEP EXCLUDED? 0 N rA 085~5104747 01/01/2021 01/01/2022 E L EACH ACGDFJJT $ 1,000,000 w-dabuyre we E.L.DISEASE-EA EMPLOYEE S 1,000.000 wder U drP4 0FOPEMr0NSbWgw ELomeASE-Poucy uwr S 1Ao0,000 MMCRMONOF OPEMTKONStLACAIMM I VEKrAM(ACORD 101.Addkkmgf Rwuft SchmfWa.aw bo aUadhed if mm sp=e fs row d Town•of Southold Is listed as additional insured with rasped to the general Gabglty policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION GATE THE3REOF, KCMCE WILL BE DELIVERED IN Town Of Southold ACCORDANCEmm THE POLICY PROVISIONS, PIT Box 178 AUMOR1ZEDREPRESERrAM t'eoDtXIIG,NY 113.58 rsRceartmaicon.wc ®198&2015 ACORD CORPORATION. All rights reserved. ACORD 25(,2016(03) The-ACORD crams and IDgo are registered mance of ACORD GENERAL CONDITIONS,OfFPERMTF APPLICATION/PER� FOR JUGHWAY EXCAVATION AND REPAIR 1. Permittee's Contractors to Camply with Permit Reaiiirements•-The-Permittee i responsibly 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 respec t'to the-permitted.activities,-an&such persons shall be required to coImpl'y with all permit requirements. _ 2. No Right to Trespass-or Interffere,with Private Pi operty Rights• This permit does not conveyto the permittee any right to trespass upon the lands of adjacent property'bwners i order to perf#in'the.permitt6d 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 Fature W hwav-Maintenaned: -If future operations of highway maintenance projects by the Town of Southold require an alteration iir'the pasitian afthe utility,structure_'- ` or work herem authorized;or if,in the opinion of the Highway Superintendent;the work,performed undei 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 modificatiort of the'highway hereby authorized'stiall not bey"cdr>6pleted Additionally,the permit maybe revoked if the Highway Superintendent finds that the:issuance of the permit was illegal or unauthorized or that the applicant-failed t0 comply with any of the tern' and; conditions of the permit or Chapter 237 of the Town Code. 4. Revocation of the Permit by the HiAwav Superintendent--•If theRighway'Superintendent deenis•it necessary to-revoke this permit and the project hereby authorized fhas not:b:eedcompleted;the apfpl cant shall;without expense to the Town and to such.extent and in such.tie andmaiiner as the SuperinteIIdent " may require,remove,all or any portion ofthe un6ompleted uti*- ,struct<ire or fill andiest Dre.thesite,toJts- . former condition. ' 5. Notice of Commencement:At least 24 hoursprior to coimdncehaent of the prolect;•the permittee and/or' contractor shall notify the Town Highway Department in writing that they are fully aware-of and understand alf terms and project conditions of this permit. Uponcompletionof the world-the rontFactor. shall provide photographs of the completed work to the Town Highway Dc patent,and reques e a Fiina1 inspection 6. Storage ofEouipment&Matteriais:r The storage of construction�equtgtrient`a or materials s be-, confined within the:protect work area and/or 4acent areas where- permission/legal,access,has been' " obtained in a manner that does not interfere with normal highway-iraf ic: 7. Utility"Mack-Olds: The Applicai%t/Contractor shall be responsible-for verifcafiari'af all exi ng,utnity: , mark-outs and•shah take all precautions to protect same.•.Damage tri existing utilities•shall be the"' responsibility of the contractor and shaRbe repaired at the c6rifiictoes expense. - - 8. Road•Closures: All scheduled road Closures must,first receive writtenIpermissiontions the:Southotdlbwn' Beard prior to closing a road. Temporary-lane closures may be permitted:with the,appr war 6f the Highway, Superintendent. This item wiTinduded but not'be limited to,the•iFi�or of apptopiiate;s;gnages aril flag Hien to stop and start,traffic to allow for single lane traffic:-Road,Closuzes due tci':itnfoFeseen emergencies require iim�ediate notification of the Highway Department aud;sliail-lie limited tb=Immediate and/or expedited restoration,df-the Work Zone. - 9. No CoustructiowDebris:in Road Shoulder Area: All Constructii mbebris shall be rernoeed frci*-tliek9b _ site on a daily basis: All stockpiled sor7;as well asall Votther,project materials,that writ be staged;withiri°tire'° _ Right-of Way must be define .with repect�ive'signage or other means•to meet the Eriva�requiiereeiits of the NYS DOT Constriction Standards. GENERAL CDNDMON&OFTERAffT APPLffCAnompmwr FoR HIGHWAY ERCAVATioN AND REkm (Continued) 10. Install_Maintain Erosion•Controls: Required Erosion ControlMeasures(i.e:silt fencing)is to be placed-- on the downstope edge of any disturbed.area. This sediment barrier i•s to be,put in glace before any disturbance of the ground occurs and is to be maintained in good functional condition until°thick vegetative- cover is established. I L Clean Dill Only: All project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,slag;flyasli, broken concrete or demolition debris). All unsuitable soils excavated at,the site(%e.Clay,Bo&'etc:)are to be removed from the site and not used tobacklEll 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 coi pletlon.: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. BackUH&Comp action of all Excavations: Back Fill shall consist of-clean,fill or soils which-exhibit a well-defined moisture density relationship as determined to-be inaccordance with ASTMVI 3 698. Fill s•hall be placed in maximum lifts of twelve(12")inches thick and shall be mechanically compacted to a Ninety-, five(9511/o)percent maximum dry density. Suitable hydraulic compaetion 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 locatedwithin 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 mad pavements must be reconstiacted 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. r5. Schematic Plans with all TechAical•infformation and Scale of Work: Ta 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 Boles 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: ARTavem ent sections must be reconstructed in the following manner;- Wow:when Concrete Pavements are Prmn4 Please review Restoration regnir ememfs with die Highway Superintendent} a) Complete all backfill&soil compaction work as needed to provide a suitable sub-base; b) Over-cut existing asphalt belt hole or trench by twelve(127)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 mutate requirements of the Southold Town Highway Specifications- 17. Trenchine of Pavement Surff Ices Exceedint=One Hundred 1001)Feefhi'Le •-All-trehching of pavement surfaces exceedirig lOO"in leirg6p usi f M be recoristrueteel;t®zi eet the require egts.of Items. #16 as noted above. Once'a�ll pave11*At teeonstrucfion is. sa completed to the- tisfaction of'tlte=Highway Superintendent,the entire road section and/or width of road-over le-enti"length-of bench-sliall:be` repaved with a two(2")inch lift of Asphalt(Type 6)Wearing-C,6 ufse,gN icai,shoulder to-shouldei): - J&M Long Island, Inc. P 0 Box 2507 Southampton, NY 11969 (631) 287-0580 283-5898 !.0« p/4A -'e,,r a/ecT�e Seh vie.4e of 13S'a ,day SIM& Ad 6r4e-y a z N V x a 4 - d C ¢lls ten'.