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HomeMy WebLinkAbout1150 Calves Neck Rd Pemr t-No. r TOWN OF SOUTHOLD IqQO IWAY DEPARTMENT "Y Peconic Lane f ., w . . - Peconic,New•York 11958 -� (63-1)765-3140 APPLICATION!PERI4IIT'FORMIGHWAY EXCAVATION AND REPAIR APPLICAnON IS HEREBY made to the Superintendent of Highways of the Town.of Southold for the issuance of an Excavation Permit pursuantto Chaliter 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 ofpenmr-and"Special Conditions",,ifanyand.to permit authorized inspectors to make necessary inspections,of the job,site. Printor Type Name of Applicant Phone Number Address of Applicant x G /'- A R-7 -A/ /7 2. �d�/`1L�hr 7s1 � sG �` sti mP 'ny c_ ,I/Al'V'0 Name of tiactor Phone Number Address of Contractor Name of Prope�rtty Owner Requesting Servcc�(if applicable) Address of Owner 4. &r� 6^�Ci.i�G,V.� I /�Q!/F'!f' /4�� G/ dtl,- 'sf r1//e-N 4 e4X'C.T Work Description and Locaho (Street Number;Haniet,Cross Street) j! (a) Is construction located withk 75 feet of tidal wetlands? *Yes No k *If yes,other TovvA-permits may-be required. NOTE: All information requested by this Signature of Wcant Application/Permit Form is Required for a complete application! r 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 40ining premises,public streets or areas,and give a detailed description of all site-aaid pavement iesteaationi work. - _ - I I . (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— I.at , 7. Starting Date: �� /��! Cianigletion IJate: .� /i�� 8. Work Schedule: Phase Comoletion Bate Excavation /�►/1 W©rk'SclFedule Facility Installation •. Must be provided Backfill&Completion for consideration as a Pavement-Replacement Complete Application. 9. Under wh"authority is application,being Facade: ' X/,tor9 See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. EstiamtedCostbfPfdposedWork:, ALL»,GQ 11. ReFinarks: a•� o Ze le, A G G �L f YA D-39 1 of 3 12. insurance Coverage:(Attach Copy) (a) Insurance Company .�y, Q ��,s u v-� c e Ca, (b)-,Policy#: -GZ 4,T-_X175 od xc (e)State whether policy of certification on file with the Highway Department: Xlod (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$2,000,000 general aggregate. 13. Seeeiiity:' (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided-- 2 years or 3 yam_ 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. /Service Connections excavations @$50.00 $ 3-0.CEJ 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 $ H Utility Repair Excavations @$1,000.001 Each: $ No. Additional Repairs of Same Service @$500.00/Each $ No. TOTAL$S�SO,OIJ F. Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. 6q-5,C #a10,-?4<1J20 Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: in rdance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any) h SUPERINTEND A S TOWN OF SO Vincent M.Oil o zdc � I® Date Date Deceived by the Town`Clerk j �q DatePe imit Issued 1 1 Permit No. 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_ r- D-34 2 of 3 Copy Distribution: Permit# I LI Ilighway Department Engineer(with.page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified is 2nd 3- 4m (To Permit Clerk) REMARKS CODE IB Improper Barricades IL Improper bights 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) ZIPS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-34 3 of 3 CERTIFICATE OF LIABILITY INSURANCE 111114/2021 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: R the ceffiflcate holder is an ADDITIONAL INSURED,the pollcy(fes)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and eandi8ons of the policy,certain policies may require an endorsement. A statement on this cerUflcate does not confer ri to the certificate holder in Rau of such endorsemen s. PRODUCER SEs Nate Pens/ Quinton Insarnnce PHONEeft (600)454-1970 Fmr-AX Na (585)388-9531 AIL 2700 Elmwood Ave E RESS.. service@qutntoninsurance.eam INSURERM AFFOROINGCOVERAGE NA(ce Rochester NY 14618 nNURERA: ERIE INSURANCE CO 26263 INSURM INSURERa: FLAGSHIP CITY INSURANCE COMPANY 35585 J S M Long Island Ina. INSURER C: P.O.BOX 2507 INSURER D. INSURER E: SOUTHAMPTON NY 11969-2507 1 INSDRERF: COVERAGES CERTIFICATE NUMBER- REVISION NUMBER-- THIS UMBER: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. LTR riPEOFINSURANCE ADDLSUa POLICYNUMBER POLIO EFF PUMpAnXP LIMITS X COMMEtCEALGOMeiuABUTY EWACCGURRENCE S 1,000,000 CLNMS.MADE�OCCUR PREMISES cem mnee $ 1,000.000 X Primary&.Non Contributory MED DIP(Anyane person) s 5,000 A X Contractual Liability Y (248{5950066 12!0912020 1210912021 PERSaNAL&ADVI,YJURY s 1.000,000 GWLAGGREGATEUMnAPPLIESPER: GENERALAGGREGATE s 2.000,000 POLICY JPRO- [—�LOC PRODUCTS-COMP/OPAGG s 2.000.000 OTHER: S AUTOMOSMEIJASaaY UUMBINmsur.LELW S 1.000.000 ANYAUTO SO°(LYINJURY(Perparsaa) S A OWNED X SC14ED� Q12-6940012 1210912020 12/0912021 BODILYWuRY(PcraocUnd) S TO AUS ONLY EMMX PRO PEt 0A11AGE S AUTOSONLY AUTOSONLY S UM M3LALIAe X OCCUR EACHCCCURRENCE s 1.000.000 A mxCESsLIAR CLAIMS-ME 036-5970028 12!0912020 1210912021 AGGREGATE s 1.000,000 ICED JXJ RETENTM5 10,000 s WORKERS COMPENSATION PER GER ANDEMPLOYERS LOUR dIV srATrITE rz YIN ANYPROPRIETOMPARTNERIEXECUTIVE -- ELEACHACCIDENr S 1.000,000 B OFRCERIME BENEXCLUDEDT rN Trp ' 065 104747 01/01/2021 01/01/2022 ¢renda utybtNH1 E.1.OLSEASE-EAEMPLO s 1.000.000 aESCRIPPTO;deVOPERATIONSbelow EtDrsEASE-POLtGYLI4di7 s 1.000.000 DESCRWUONOFOPERAAONSILOCAMONSIVEN CLES(ACORDI91,AdManaNRamuksSdiedula mybeaNadtedifmawsP=aLaca*dn cQ Town of Southold is listed as additional Insured with respect to the general liability policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE WIRATIONI DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 178 AUFHORRGEDDREPRESEHTATIVE Peconic.NY 11958 4&25 , 'fes rsncevrt+owccaa.a�ec Q 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered maflrs of ACORD 5 GENERAI:'C@NllIT @NS @ z PE-RwT APPLICATI@NIPERMIT FOR RIGRWAY EXCAVATION ANWREPAI R , 1. Fermittee's Contractors to Comply with Permit'Regidremeats: 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 generafconditions 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 Tresnass'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 perflirm"the permitkd- 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 Ifghway and Future Hitchwav NWntenaned:.if future operations or highway ' maintenance projects by the Town of Southold require an alteratiaii in,the position,of the utility,.structure _ or work-herein author zed,or�in the opinion of the Highway Superintendent the work.peifoiiaied under this permit shaIcause-unreasonable obstruction to required highway maintenance or endanger i re health; " safety and/or welfare of vehicular or pedestrian traffic,this permit shall.be revoked and,the'utility, " structure;fll,excavation,or other modif cation`of the1ighway hereby autiiorized-shall notbe'caiiipteted: Additionally,the permit may be revoked if the-Highway Superintendent finds that thd�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 E¢hwav Superintendent•=lf the•Highway Superintendent deeffis-it-• ' necessary to revoke this permit and the project hereby,authorized.hasnof b iei ;coiiigleted;-.tlie applicant shall;without expense to the Town and to such extent and in-such time and,manner as the'-Superizit&(!ent may require,remove all or any portion of the uncompleted utility,'struetiireror fill"�arid-restore the'sit�to;kts former'condition. 5. Notice of Commencement. At least 24 hours prior to commencement:of the project;•the permittee-and/or - f contractor shall notify the-Town Highway Department in writing that they are-fully aware of and = understand airterms andpioject conditions of this permit. Upon completion ofthe wirrk the contractor shall provide photographs of-the completed work to the Town Highway Departffient•and request.a Final inspection. :• (a. Storage of En meat&Materials:'The storage of construption'equipment and/or materials shall be, confined within the project work area and/or adjacent areas where_permission/legal access has-bi ea - obtained in a manner that does not interfere with normal highway`traffc. 7. UtiEi Mack=Outs: Tlie Applici i Contractor shall-be responsibi d for verif cation of all existuig utitity`' iaik-outs and-shall take-all precautions to protect sante. Damage to;existing utilities shall be the responsibility of the contractor'and shall be repaired at the contractor's expense: 8. Roacl•Closuces: All scheduled road closures must.first reeeive"'*itteii"permissioti front the'Sduthol[d Town- , - Boardpiior enclosing aroad. Ten6porary lane closures nay lie permitted with the appFoval of the Hig$i ay, Superintendent. This item,'will included but not'be"linuted to the ipstalof aFPSolaiiate;sigriage orid° flag men to stop and start-traffic to allow for single=lane traffic. Roa&Closures_due'to:unfgreseea _ emergencies require irti�te notification of the Highway Departrmnt-acid,-shid,lie limitoqmmediate ` - and/or expedited restoration of the Work Zone: 4. No Consti^a,ction-Mbrisin R624,Shoulder,Area: All Construction,Dtbsis sliail be iemo46d'fr6 utlie y6ili - site on a daily basis. All stockpiled soif,as well as all-oiherproject materials,tli'at will be-Staged- Right-of Way must be delineated.with reflective signage or od es means to_'meet the m�iniinuria requirenoenis of the NYS DOT Construction Standards. QNERAII! mQM QNSIOR=PERIVOT APPLICATIONMERA T FOR HIGHWAY EXCAVATION AND REPAIR '(Continne'd) 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 glace before any disturbance of the ground-occurs and is to be maintained in good functional condition until-thick vegetative- cover is established 11. Clean Rill Only: All project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,slag;flyash,- broken concrete ordemolition debris). All unsuitable soils-excavated at'the site(i.e.Clad,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 arras of soil disturbance resulting from the approved prolect,sh&-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 andlor jute matting until weather conditions favor germination. 13. Bach&Compaction of all Ego avations- Back Fill shall consist of clean fill or sods which,exhiibit a well-defined moisture density relationship as determined to be in-accordance`with ASTMD 698. Fill,sliall- be placed in maximum lifts of twelve(12")inches thick and,shall be mmMbanically compacted to a Nihety- five(9511%)percent maximumdry density. Suitable hydraulic cci mmpaWon by water jetting atthree-foot " intervals will also be permitted subject to a project specific approval by-the Highway Superintendent. 14. Restoradon of the=Road Shoulder Area: All man-made improvements located within existing road' shoulder areas must be protected to thegreatest extent practical. Items would-include but not be limited-to driveway&private road aprons,mail boxes,sprinkler systems,trees and ornaimentalplantings. 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. M Schematic Plans with all Ti echnical 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 iii the Southold Town Highway Specifications. 16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner;- (Dote:when Concrete Pavements are Prmig,Please review ResWration mqW' w writ 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 ail 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 lints) All work listed herein must meet the minimum requirements of the Southold Town Highway Specifications. 17. Tr`enching of Pavement Surfaces Exceedini!-One Hundred.41 01)Feet;in Length: All<trenching,Of pavement surfaces exceeding 1001 iia-length=must-first be reconstnicte tD'mmieet the requireFnelits of Ite a, #16 as noted:above. Once all reconstructionPavement is corn pte�gd to the the Highway Superintendent,the entire roadsecti ,0606r width oaf,road'ove-r�e-enti a lengtroffredch-shaltbe` repaved a two 2 inch o€ halt e , Fa ( ") ASP (gyp 6)Wearing Couise,(Tgical;'shoulder tQ"sho�uFder):' JAM Long Island, Inc. P 0 Box 2507 (631) 287-0580 Southampton, NY 11969 283-5898 fertdc,e 0.4 /ISO - Af -CX t h a� C6 0 or CA a J ` y