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HomeMy WebLinkAbout640 Skippers Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 05/05/22 Receipt#: 297715 Quantity Transactions Reference Subtotal 1 Excavation Permits 1575 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#11508 $550.00 J & M, Long Island Inc Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: J & M, Long Island Inc P O Box 2507 Southampton, NY 11969 Clerk ID: LYNDAR Internal ID: 1575 Is Permit-Na. TOM OF SOUTHOLD FO t HIQHWAY DEPARTMENT Peconic Lane Peconic,New York 11.958 (631)765-3140 APPLICATION/PERMIT 1a oR HIGHWAY AND REPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town.of Southold for the issuance of an Excavation Permit pr rsniant'to Chapter 237-ofthe Cod&6f 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:ofPermit--and."Special:Condition';; anyiand.to permit authored inspectors to make necessary inspections,of the job.site. Print or Twe h i(14 C Name ofApplicam Phone.Number Address of Applicant 2. ���"� �far�� 71/617Ac Ae &Y X/y Name of Confis6or Phone Number Address of Contractor L 3. Name of Property Owner Requesting mnc(-,(if applicable) Address of Owner 4. r� �Z3 ,,- . 4e ter /h97� /J Ca 0e, 'rerr,7� 'a� � Work Description:and Locatio (Street Number;Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes Na *If yes,.other Town permits maybe required. .2�,Z NOTE: All information requested by this Signature of t Application/Permit Form is Required for a complete appEcaflont _Z /:4 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 bythe Town Clerk. 6. Tax Map No.: District 1000 , Section 17 , Block D V . Lot 7. Starting Date: _; /PCA--2- Completion Date: 8. Work Schedule: Phase Cam Ieti_on Date Excavation 3�� Work'Sciiedule Facility Installation j Must be provided . Backfill&Completion , , for consideration as a Pavement Replacement /6 Dpph) -�r Complete Application. 9. Under which authority is application:being made: See Town Code Chapter237(L)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost afPtoposetl Work: $ 11. Remarks-1 [,c?Ore ,.,J,- I.PG I4P /^t��L� d. f�G'�El�/� �%1/i ✓XML h/r�r'f�h D-39 I of 3 12. Insurance Coverage:(Attach Copy)/^ _ (a) Insurance Company- L rf 2 .T hSvr4 hCe C4, (b)-,Policy#: 00C< (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 worn performed: $:1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: (a).Suety Bond or Certified Check provided in the total Amount of$ (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 Dole and/or every road opening or excavation within any 50'Radiuswhether 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 No. A2. /Additional Excavations same service @$20.00 $ No. B. Trench Excavations 18"in depth or less ' Total Lineal Footage of Excavation; LF.@$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. TQTAL$ F. Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. <4se /r/© ges Authorization is hereby granted to the Town Clerk of the Town.of Southold to issue a Highway Excavation permit to: in accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto. SUPERI1,1TEND24T OF HIGHWAYS TO OF OUTHOL D,NEW-YORK rEt ZooWlq zf4Z!1�� S Date . 'Date Received by the Town,Clerk I Date-Permit Issue. 5 ' - �.Z Permit No. l 5 7 5 -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 tip for inspection,on site,during construction. D-39 2 of 3 Q)Fy Distribution; Permiti:# 1 S15 Flighway Department Engineer(with-page 3) Applicant Towwn Clerk(Original) INSPECTOWS RECORDS Inspection Date Findings(use code) Applicant Notified L ZDd 3rd (To Permit Clerk) RENLARKS COBE 'IB Improper Barricades Improper lights ST ``Sunken Trench or Excavation UTNE : .Unable to Measure(dqjelo,backfilling) BUC Building Under Construction WtP WorkInTrogress DB Improper BackOR(too high,not sufficient) BFS Inspector Bolding for Final Settlement of Excavation `RFR ..ReadyforRelaw D-39- 3 of 3 GENERALCONDITIONS,OF PERMIT APPuICATION/PERAur FOR HwHwAY.EXCAVATION AND REPAIR 1. PermittWs Contractors to Camoly with Permit Requirements: The Permittee is responsible far informing its independent contractois;employees,-agents and assigns of their responsibility to comply with this permit,including all-special/site speck.and generaf-condition unposed 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 Interferewith: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 theppermitted.. 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. 1 Protection of the IU>=hwav and Future Highway Maintenance:',If future operations or highway. maintenance projects by the Town of Sbuihold regnire art alteration in the°position ofthe.utilrty,structure_. or work herein authorized,or fj in the opinion of the Highway Superiatend6ntlthe work pe formes:u ides this permit'shaIl-cause unreasonable obstruction to-required highway::maintenance.or.endanger ihehealtli; safety and/or welfare of vehicular:or pedestrian traffic,this permit.shall be revoked and.the.utitity, structure,fill,excavation,or other modification of the highway herebyauthorized-.shall natbe corepleted: Additionally,the permit maybe revoked if the Highway:Superintendent finds that-the issuanee 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. Revocationof:the Permit by the HWkway Sunerintendent• -Ifthe Higliway_Superintendent:deen?s:it necessary to revoke this permit and the project hereby authorized has:net beerf completed,me applicant shall,without expense to the.Town and to'such-extent and in such it�e.and rffianner 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:permrtteeand/or- contractor shall notify the Town Highway Department:in writing that they are fully aware,of arid understand all-terms and project conditions of this permit. Uponcompletionof the work;the contractor.. " shall provide photographs-of the completed work.to the:Town:Highway Department and request a Final inspection- 6. nspection6. Storage a€Equipment&-M,:it eriais: 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_ Ut itv Mark-Outs: The Applicant/Contractor shall-be responsible for verificatron"6f,ill.exrsteBg utility mark-outs and"shall take al precautions to protect same. Damage-to"existing utilities shall lie the;. responsibility of the contractor and shall be repaired attthe contractor's expense. 8. Road-Closares: All scheduled road closures must,first receivewritten permission from the';Southold Town Board prior to closing a road..Temporarylane-closures maybe-permiit*-with the approval of the Highway Superintendent. This item wiU.included.but not-be limited to the installation.of appro­-­­&.e,--;­ ­­ ,­rign ;, .. flag risen to stop and start traffic to allow for:single lane traffic. Roa&Closures du'to unforeseen emergencies require immediate notification of the Highway Department.and shall be limited to ut iedrate and/or expedited restoration,of the Work Zone. 9. leo Construction;Debrisin Road.Shoulder Area: All Construction Ddbris sltall lie removed fro "thelpb° site on a dailybasis. All stockpiled soil,as well as all oilier project materials tha'r wile-be staged witnirt the° . " Right-of Way mustbe delineated,withreflective signage ar other rneaus to-meet they ii r,m riu requirements of the NYS DOT Construction Standards. GENERAL CONDMONS:OF PERMT APPLICATTOMPERff-rFOR HIGHWAY EXCAVAITO_ N 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'pre ject back fill shall consist of clean sand,-gravel or soil(NOT asphalt,slag;flyash,' broken concrete or demolition debris). All unsuitable soils excavated atthe site(Le.Clay;Bog;etc.).are to be removed from the site and not used to backfill any excavation within a`Town Highway. 12. AU Areas of Soil Disturbance: All areas of soil disturbance resulting''froin the approvedpre jed 9611 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 henthe area shall be stabilized with straw,hay mulch and/or jute matting untilweather 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 ASTIV ,698 -Fill§lull- be placed in maximum lifts of twelve(12")inches thick and shall-be mechanically compacted to a Ninety- five inety- f ve(951%)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 Shoalder 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. M Schematic:Plans with all Technied-infoimatioit and Scoo-e ofWork• To reasonably and adequately describe the proposed work,accurate schematic site plans must beprovided,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 hoes or width- of trenching must be indicated.by dimension or labeling. This schematic site plan must proyide.details•on all restoration-required to meetthe requirements of these General Conditions and requirements found:in the. Southold Town Highway Specifications. 16. Pavement-Reeonstruction�: All Pavement sections must be reconstructed in the"fallowing.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(I2")inches on all sides; c) Install a compacted lift of 4 thick Stone Blend base(RCA Blend mustmeet NYS DOT Specification);- d) Install a two and one half(2.5")inch compacted lift ofAsphalt Base Course; e) Install a one and one half(1.5")inch of Asphalt(Type 6)-Wearing Course_ (Provide AC at altJ6ints) All work listed herein must meet the r=`mum.requirements of the Southold Town Highway Specifications. 17, Trenching of Pavement,Surliaces Exceeding=One Hundred:'(I00')Feet in-Ledgth All;trenchingof pavement surfaces exceeding100"I' Pen gilt must fist be reconstructed#o meet=the regitireuaents of Iterii #16 as noted.above. Once aI paveitieiit.reconstruction is.completed to the satiafactaa of the Highway Superintendent,the entire road section and/orwidth of road over' entire length of trench shall be' . repaved with a two(2")inch liftof Asphalf,(Type 6)Wearin E;ouise; i � - g gyp cal :shaulder to shoulder}: . Ja M tong Island. Inc. P 0 60X.2507 Southampton, NY 11969 (631) 287-0500 283-5898 SQ rvsLP .. ���r�G r• Ler . 1 0 • i�raly� T�E is/P 7G `�/1(� Gr�S,S IV4 Red t Apr 29' 2022 07,31 J&M Long Island, Inc, 727-786-2861 page 1 7 ® DATE(MMI.DIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/16/2021 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; If the certificate holder is an ADDITIONAL INSURED,the policy(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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO NAME. Nate Perry _.. Quinton Insurance PHONE (800)454-1970 FAX.No): (585)388-9531 DR service uintoninsurance,com _ 2700 Elmwood Ave DRESS; �q --- INSURERIS)AFFORDING COVERAGE IT NAIC b Rochester NY 14818 INSURERA: ERIE INSURANCE CO 26263 INSURED raSURER B: FLAGSHIP CITY INSURANCE COMPANY 35585 J&M Long Island Inc. INSURERC: _ P.O.BOX 2507 INSURER D: INSURER E, — SOUTHAMPTON NY 11969-2507 INSURERF: 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. INSR TYPE OF INSURANCE ADDL WHOA POLICY NUMBER MM/DD/YYYY ICY EFF **MMIDD FLICY EXP LTR LIMITS x COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $_1,000,000 DAMAGE TOR Nf TED ODO CLAIMS-MADE D 1,000, OCCUR PREMISES cx occurrence) $ 0 _ X Primary&Non Contributory MED�m person) $ 5,000 A X Contractual Liability X Q45-5950066 12/09/2021 12/09!2022 PERSONAL&ADV INJURY S 1,000,000 - GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000_ POLICY PRO-JECT PRODUCTS LOC PRODUCTS-COMPIOP AGG S 2,000,000 $ OTHER: COMBINED SINGLE LIMIT g 1,OOD,000 AUTOMOBILE LIABILITY Ea accident 0.00 .. ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED Q12 rjg40012 12/09/2021 12/09/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED V NON-OWNED Peraecidentl $ AUTOS ONLY /� AUTOS ONLY "" X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAS CLAIMS-MADE 036-5970028 12/09/2021 12/09/2022 AGGREGATE i$ 1,000,000 DEC) /ti RETENTION$ 10.000 _ $ WORKERS COMPENSATION STATUTE IX ERH_AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTHER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICERIMEMBEREXCLUDED? � NIAJ Q85-5104747 01/01/2022 01/01/2023 DISEASE-EAEMPLOYEd5 1,000,000 (Mandatory in NH) - --- If yyon describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 I DESCRIPTICN OF OPERATIONS below I DESCRIPTION OF OPERATIONS/LOCATIONS[VEHICLES (ACORD 101,Addtllanal Remarks Schedule,maybe attachadif more space ie roqulrod) 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 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold PO Box 178 AUTHORIZED REPRESENTATIVE Peconic,NY 11958 R5 RGEI.IT FOR 1.<.O.R,INf. (D'1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD a � l f Apr 29' 20� 07;31 AM Long Island, Inc, 727-786-2861 page 2 NOR Workers' CERTIFICATE OF sTATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of insured(use street,address only) 1 b.Business Telephone Number of J&M Long Island Inc. Insured(727)410-6777 P.O.BOX 2507 1c.NYS unemployment Insurance Employer Registration Number of SOUTHAMPTON NY 11969-2507 Insured Work Location of insured(Ody required it coverage 1s sPeciflcally limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations h New York State, I.e.,a Map-Up PrNcy) Number 11-3315081 2.Name and Address of Entity Requesting Proof of Coverage 3s,Name of I nsurance Carrier (Entity Being Listed as the Certificate Holder) FLAGSHIP CITY INSURANCE COMPANY 3b.Policy Number of Entity Listed In Boz"t a" Town of Southold Q85-5104747 PO Box 178 Peconic,NY 11958 3c. Policy effective period _0110IL2022. to OILOIL2023 3d.The Proprietor, Partners or Executive Officers are F included.(only check box If all pxtneworficem included) all excluded or certain partnerslofficers excluded. This certifes that the insurance carrier indicated above in box'7 insures the business referenced above in box-1a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form, New York(NY) must be listed under Item A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of insurance to the entity listed above as the certificate holder in box"T'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.) Otherwise,this Certificate Is valid for one year after this form Is approved by the Insurance carrier or Its licensed agent,or until the policy expiration date itstiod In box"3c",whichever Is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contractof insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract Issued by a certificate holder,the business must provide that certificate old'er with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business Is complying e mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the Insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: D. Gordon Quinton (Print name of authorized representative or licensed agent of insurance carrier) 03/02/2021 Approved by: (SiylaturO (hate} Title: President Telephone Number of authorized representative or licensed agent of insurance carrier. 585-244-9004 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are„NOT, authorized to issue R. v✓ww.wcb.ny.gov C-105.2 (8-17)