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HomeMy WebLinkAboutCedar Dr R-mnit No. 1 w� TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane y Peconic,New York 11958 c (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 Tyne I. �2��� n.lf ry c7�tin 'l�i/s'/ise, ✓f (o,51'774--0 Zq 9 f. f✓i v' AJO Ygrnooro �� A 911 i m-49 Name of Applicant Phone Number Address of Applicant 2. Name of Contractor Phone Number Address of Contractor r 3. Name of Property Owner Requesting Service(if applicable) {� Address of Ow�n+er) �� 4. , ✓l�-e 1 Std C�`-7'� — 1"e�cT I Jr,(�e ( �} J / s 11V- Work - mss f pdazrl'�� Work Description 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 tignature of Applicant Application/Permit Form is Required for a complete application! 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: 6-,20 Completion Date: 4 —Zy 23 8. 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: 0e,6�J 15 i cD n See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ i 11. Remarks: 1�lc. JcjwgpJ -/�4TU LI1 ci J►2 c,l O Vl l Go, 330/ R A.sg ams D-39 1 of 3 12. Insurance Coverage:(Attach Copy) A ' a (a) Insurance Company: ` -e- ' .715 - (b) Policy#: (c)State whether policy of certification on file with the Highway Department: 7 z (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. �° ;"n 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. 3 /Service Connections excavations @$50.00 $ 5-0 vo 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$ (JJv 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 Excavation permit to: in accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto. SUPERINT DENT OF HIGHWAYS TOWN O UTH LD, W ORK 4 C iV ate Date Received by the Town Clerk 111` ?i� Date Permit Issued -]l(Z-i Permit No. I (pZ (A 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 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 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 pen-nit. 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 teens 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. 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 terns 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 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 DDT Construction Standards. V of 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). (del, arl8) �°S� L 3 0 s !O AC®® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDM'YY) 05/17/2023 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(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 Edgewood PartnersInsurance Center NAME:____.__. Commercial Support _ 40 Marcus Drive IcNNo Ext' (631) 390-9700 A1C No_(_631) 390-9_79_0 3rd Floor ADDRESS:Melville, NY 11747 SS: msmcertscm- @epicbrokers.com - - - INSURERS)AFF ORDINGCOVERAGE NAIC# INSURER A:MERCHANTS PREFERRED INSURANCE 112901 INSURED (631) 774-1379 INSURER B:Sutton Specialty Insurance Com 16848 R&R Construction Enterprises Inc. ----- --'- —- INSURER 9: Fichter Brothers LLC INSURER O: 282 Line Road ------ --'-'-----1- .. Manorville, NY 11949 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 17472 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 __________T. __- LTR TYPE OF INSURANCE I POLICY NUMBER MMI�OfYYFYY ' MMIDD/OLICYYYYY t LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE_ $ 1,000,000 J CLAIMS-MADE 1 " I OCCUR Y i CTRIO08418 ;04/20/2023104/20/2024�PREM SES�aoccur encs) S 500,000_ j i MED EXP(Any one person) (S 15,000 PERSONAL&ADV INJURY S - 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: j GENERAL AGGREGATE 'S _ 2,000,000 PRO- 1 POLICY"JECT -J LOC I I I i I PRODUCTS-COMP/OP AGG $T2_,000,000 OTHER: jEmpl Benefits LiabjS 1,000,000 AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT (Ea accldenq _ _S _ }r_ ANY AUTO ? i BODILY INJURY(Per person) «5 OWNED SCHEDULED --�---- '-— ----- 'AUTOS ONLY AUTOS I BODILY INJURY(Per accident);S --- HIRED NON-OWNED : PROPERTY DAMAGE I S i AUTOS ONLY ;AUTOS ONLY I Per accident -,__ $ I I UMBRELLALIAB uXJ OCCUR ! Y ISCEX0300000283-01 ,01/12/202301/12/2024 EACHOCCUR_R_EN_C__E S _3,000-,000 X EXCESS LIABCIAI -T T_ - IMS-MAGE I I AGGR_E_GA_TE _ IS 3,000,000__ DED X I RETENTIONS 10,000i 1 WORKERS COMPENSATION i ,PER I Ulm- YIN TH- AND EMPLOYERS'LIABILITY Y I N I f _.___- '_ !STA UTE ' 'ANYPROPRIETORIPARTNERIEXECUTIVE I E.L.EACH ACCIDENT !S OFFICERIMEMBER EXCLUDED? NIA( i I - --- — ----- (MandatoryinNH) i ( 'E.L.DISEASE-EAEMPL_OYEE!S yes,describe under DE.L.DISEASE-POLICY LIMIT;5 DESCRIPTION OF OPERATIONS below ' I i S DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Town of Southold Peconic Lane Peconic, NY 11958 is added as additional insured for general liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Peconic Lane AUTHORIZED REPRESENTATIVE Peconic, NY 11958 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Page 1 of '_ R&RCONS-01 BOKULA .A�R�►` CERTIFICATE OF LIABILITY INSURANCE __[7DATE(MMfDD/YYYY) 511612023 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 TACT Rollin Becker Inter-Insurance Agency Service PHONE FAX 380 N Broadway,Suite 400 AIc,No,Ext):(516)352-7500 Arc,No): Jericho,NY 11753 Ao AIL .rbecker@interinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:HARTFORD INSURANCE 30104 INSURED INSURER 8:ShelterPoint Life Insurance Co 81434 R&R Construction Enterprises Inc INSURER C; 282 Line Rd INSURER D: Manorville,NY 11949 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. ILTR TYPE OF INSURANCE IINSD SWVD POLICY NUMBER POLICY YFF POLICY M DD EXP LIMITS ADOL COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F—]OCCUR DAMAGE TO RENTED PRE S MED EXP(Any oneperson) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY ET LOC PRODUCTS-COMPIOPAGG OTHER: _ S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANYAUTO BODILY INJURY Perperson) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident S AUTOS ONLY AUTOS ONLY P.,.cRdent AMAGE $ S UMBRELLA LIAR H OCCUR i EACH OCCURRENCE s EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS I S A WORKERS COMPENSATION �( PER OTH- AND EMPLOYERS'LIABILITY Y/N ATIJTE Eft ANY PROPRIETORIPARTNERIEXECUTIVE 12 WEC FX6968 10/112022 101112023 1,000,000 OFFICERIMEMBER EXCLUDED? ❑Y N/A E.L.EACH ACCIDENT S (Mandatory in NH) E.L DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-PO'-ICY LIMIT $ B Disability DBL175701 1/1!2023 1/1/2024 STATUTORY DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Peconic Lane ACCORDANCE WITH THE POLICY PROVISIONS. Peconic,NY 11958 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 07/12/23 Receipt#: 313180 Quantity Transactions Reference Subtotal 1 Excavation Permits 1669 $650.00 1 Excavation Permits 1670 $600.00 Total Paid: $1,250.00 Notes: Payment Type Amount Paid By CK#8024 $1,250.00 R&R, Construction Enterprises Inc. Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 i Name: R&R, Construction Enterprises Inc. 282 Line Rd Manorville, NY 11949 Clerk ID: JENNIFER Internal lo: 1670