HomeMy WebLinkAbout1500 Latham Ln Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 03/02/23 Receipt#: 308517
Quantity Transactions Reference Subtotal
1 Excavation Permits 1641 $550.00
Total Paid: $550.00
Notes:
Payment Type Amount Paid By
CK#11484 $550.00 Center, Island Services Inc
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: Center, Island Services Inc
67 Sycamore Street
Patchogue, NY 11772
Clerk ID: JENNIFER Internal ID: 1641
_Permit No. `1
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958 eo # ,;
(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
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
Name of Applica Phone Number Address fos Applicant
2. 0Znkr 1,5(01 08 &A!�V jCy
Name of Contractor Phone Number Address of Contractor A
Name of Property Owner Requesting Service(if applicable) Address of Owner
Wor Description and Location(Street Number,Hamlet,Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No �Q
*If yes,other Town permits may be required.
NOTE: All information requested by this Signature of Applicant
Application/Permit Form is
Required for a complete application! 2 ita / 2-OL-5
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.
.,376. Tax Map No.: District-1000', Section 15 , Block 9-, Lot 1 .3-
7.
. Starting Date: �`"'j � \/��,� ¢� 3�1p n 3`\O Completion Date: `
8. Work Schedule: Phase Completion Date &A
Excavation &Qom► k Work Schedule
Facility Installation ckC,,t \ Must be provided
Backfill&Completion \ for consideration as a
Pavement Replacement "n OX 93 S' Complete Application.
9. Under which authority is application being made: L �
.�h JCMLS L 4 6(2:h rn
See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified.
10. Estimated Cost of Proposed Work: $ NIA-
11.
I A— L�t�
11. Remarks: Ht SS 1 (e. �en [O U \ Q rclS� P_'l A
-.ud Cc,4--mm i L'( Y\Q. A- 12301 &L� yv c Qn -sa rne_ S l d e.,
D-39 IUD 0QeX1'rJS k4jo�A 1 of 3
12. Insurance Coverage: (Attach Copy)
(a) Insurance Company: W UnkA C, 0Q1-.:S, 2CA k! l l kr-\S• 0D.
(b) Policy#: (_5c)2-oo® a S — 1
(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$2,000,000 general aggregate.
13. Security: tfirvv�f�
(a)Surety Bond 1N \F_ _ or Certified Check provided in the total Amount of$
(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. _f/Service Connections excavations @$50.00 $ Q..6o
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$ C! �qo 666
F. Official Notice to public utilities-proof must be provided and �r
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:
in accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto.
SUPERINTENDENT OF HIGHWAYS
TOWN OF TH LD,NEW YORK
Date
Date Received by the Town Clerk 3
Date Permit Issued 312,19-3 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.
D-39 2 of 3
Copy Distribution: L
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1st
2nd
3rd
4th
(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 3
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHAVAY EXCAVATION AND REPAIR
1. Permittee's Contractors to Comply with Permit Requirements: The Perinittee is responsible for
informing its independent contractors, employees, agents and assigns of their responsibility to comply with
this pennit, 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,ill,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.
S. 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 pennitted 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-f
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).
(Fels W18)
Referral Type Referral- DSTX Ticket DSTX00172369952
Dangerous Situation NO
Temp In Place NO
Facility Riverhead Refer To Construction
Corp Account#
Sub Address 1500 LATHAM LN Census X9A107 Date 2/4/2023
Town ORIENT A p# 83 Supervisor Greene
X-Street Lands End rd oIt# Tech# 2236
Location of Repair 124 to 1500 Latham lane ell# Tech Cell 516-779-1076
H
s Low Levels
Feeder Replacement UG 650 MC2
•.• 100 feat from 20 to .. .-
3
e.
63 70 603 771
Levels MER CL US Issue
Active Active Actil a Active
Tap Tap Tal Tap
270 feet of new U/G needs to a ran fro out ut of 20 to b house 1240 Latham lane to input of 7 to b ho se 1 00.
•.
1°i d a y Inforrnatl n
Claim#
PRG# 1 800-259-8753
Tech 1 Reg Hr;__ OT Hrs DT Hrs Misc
Tech 2 Reg Hr OT Hrs DT Hrs Misc
Entry Splice Shrink
Company Comments
Address
i Phone#
270 feet of new U/G needs to be ran fro output of 20 tap by I
house 1240 Latham lane to input of 7 tap by house 1500. 1
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63
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ACOO CERTIFICATE OF LIABILITY IN URANCE DATE(MM/DD/YYW)
�� 09/16/2022
THIS CERTIFICATE ISI SUED AS A ATTER OF INFORMATION ONLY AND CONFERS N RI HTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES N T AFFIRMATI ELY OR NEGATIVELY AMEND,EXTEND OR ALTE TH COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFI ATE OF INS RANCE DOES NOT CONSTITUTE A CONTRACT BE7E N THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR RODUCER, ND THE CERTIFICATE HOLDER.
IMPORTANT: If the cer ificate holder s an ADDITIONAL INSURED,the policy(les)must h ve DDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS W IVED,subjectto the terms and conditions of the policy,certain p lici s 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
NAME: Jer nife Heiser
Nicholas DeVito Agency Inc. PHONE o . (63 )50 -6388 arc No: (631)509-0099
449 Route 25A E-MAIL
Mount Sinai, NY 11766 ADDRESS: jen 1fe devitoagenc .com
I SU ERS AFFORDING COVERAGE NAIC#
INSURERA: Atl nti Casualty Insurance Co. 42846
INSURED INSURERB: Me Ch nts Mutual Insurance Co. 23329•
Center Islanc Services Inc. INSURERC:
67 Sycamore Street INSURER D:
Patchogue, Y 11772-2$74 INSURER E:
INSURER F:
COVERAGES CE TIFICATE NUMBER: 00020246-950551 REVISION NUMBER: 48
THIS IS;TO CERTIFY THAT THE POLICIES F INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 1 HEINSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY RE UIREMENT,TERM OR CONDITION OF ANY CONTRACTOR O HER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISS JED OR MAY PI RTAIN,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 B PID CLAIMS.
INSR ADDL SUER POLICY EFPOLICY EXP
LTR TYPE OF INSU NCE POLICY NUMBER MMIDD MMIDDIYYYY LIMITS
A X COMMERCIAL GENE L LIABILITY Y L302000846-1 10/03/202 1 /03/2023 EACH OCCURRENCE $ 5,000,000
CLAIMS-MADEOCCUR PREM SES A AGE ToEa occurrence)IENTED $ 60,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 51000,000
GEN'L AGGREGATE LIMIT A PLIES PER: GENERAL AGGREGATE $ 6.000.000
POLICY JECT r LOC PRODUCTS-COMP/OPAGG $ 5,000,000
OTHER: $
B AUTOMOBILE LIABILITY CAP1079949 10/03/202 1 /03/2023 COMN
SINGLE LIMIT $ 1,000,000
IxANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS ONIRED XEDY Pe
0r a..ZIOAMAGEE
UMBRELLA LIAB j OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MAD AGGREGATE $
DED I I RETENTIO $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/ XECUTIVE ❑ NIA E.L.EACH ACCIDENT 5
OFFICER/MEMBER EXCLUDE ?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,(describe under
DESCRIPTION OF OPERATIC NS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if m)re si ace is required)
Town of Southold is included as additional insured as required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF!TH ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Of Southold THE EXPIRATIODA E THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH HE POLICY PROVISIONS.
275 Peconic Lane
Peconic, N 11958 AUTHORIZED REPRE ENT TIVE
J-H
@'988-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(2016103) The ACORD name and logo are registered mar�Cs of ACORD Printed by J-H on 09/16/2022 at 04:08PM
- r
t,'YORRIIt Workers, CERTIFICATE OF
STATE onlpensa ion NYS WORKERS' COMPENS `i ON INSURANCE COVERAGE
�=• Board
Ha.Legal Name 8 A ddress of Insur d(use street address only) 1b.Business Tc lne Number of Insured
Center Islan Services Inc. 631-475t00
67 Sycarnom Street
Y 11772 2874 1c.NYS Uneml Ivy en(Insurance Employer Registration Number n(
Patchogue,
Insured
Worl(Location of Insured(Only req fired if coverage is specifically limiter/to .1 d.Federal Em loy r Identification Number of Insured or Social Security
certain locations it,I Vew York State,i.e.,a Wrap-Up Policy) Number
11-343633
2.Name and Addre's of Entity Req.jesting Proof of Coverage 3a.Name of In ura ce Carrier
(Entlty Being Listed as the Certifica a Holder) Property & Casualty Ins. Co. of Hartford
Town of Southold 3b.Policy Num ner c f Entity Listed in Box"'In"
;275 Peconic Lane
Peconic, NY 11958 12WECAK19DRY
3c.Policv effec ive eriod
63/2-1/2022 to 03/21/2023
3d.The Proprietor artners or Executive Officers are
included.( my check box if all partners/officers included)
® all exclud. or certain parinersiofrirers excluded.
This certifies that he insurance carrier indicated above in box"3"insures the busine s r ferenced above in box"1 a"for workers'
i:ornpensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3�
on the INFORMATION PAGE of the workers'compensation insurance policy). Fhe Insurance Carrier or its licensed agent will send
this Certificate of nsurance tote entity listed above as the certificate holder in box'2".
The insurance ca rier must noti the above certificate holder and the Workers'Com en ation Board within 10 days IF a policy is canceled
due to nonpayme it of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insu ed from the coverage indicated on this Certificate.(These notices ma be sent by regular mail.)Otherwise,this
Certificate is val d for one yea r after this form is approved by the insurance ca-rieF or its licensed agent,or until the policy
,expiration date I sled In box"3c",whichever Is earlier.
This certificate is ssued as a m tier of information only and confers no rights upon ti e certificate holder.This certificate does not amend,
extend or alter th coverage aff rded by the policy listed, nor does it confer any righ s or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a Workers'Compensation contract of insura ce only while the underlying policy is in effect.
)'lease Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be
named on a permit,license ot contract issued by a certificate holder,the business must provide that certificate holder with a
new Certificate of Workers'C mpensation Coverage or other authorized prooll that the business is complying with the
mandatory coverage requirements of the New York State workers'Compensaion Law.
kJnder penalty ol perjury,I certify that I am an authorized representative or lic Inse agent of the insurance carrier referenced
above and that t ie named insured has the coverage as depicted on this form.
pproved by: Nicholas Devito
(Print nam au riiff I I- or lice d• surance carrier)�
Approved by:
/cam
(signature) (Dale)
Title: Authorized Representative
Telephone plumb r of authoriz d representative or licensed agent of insurance carr er: 631-509-6388
Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insuranee brtlkbrb are LtOLT
authorized to isf ue it.
C-105.2(9-17) vvww.wcb.ny.gov