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HomeMy WebLinkAboutLatham Ln Permit No. D TOWN OF SOUTHOLD S11FFOIt HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 (631)765-3140 41% 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 I. J7//� �C'aay /u��cs� �✓! 5e .�iic �v�/-7'71375 ,?h1 (,rte Qcl, Pk7a�u���� 1lY `'I I1C.�ci Name of Applicant Phone Number Address of Applicant 2. Name of Contractor Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable) Address of Owner 4. 17_.ra J4 cr j C — L-�1/0M Zl+k)L,'=- �- Work Description ancf Location(Street Number,Hamlet,Cross Street) ' (a) Is construction,located within 75 feet of tidal wetlands? *Yes No X *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- -- 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: -,16- ,g-3 Completion Date: 7-,;Fo -z'S 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: 64 L.J13iv"I See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ A o0o . oo 11. Remarks: I�-�I�I G,e 84cedol C#iu U >G D-39 1 of 3 12: Insurance Coverage:(Attach Copy) (a) Insurance Company: erc 7k (b) Policy#: (c)State whether policy of certification on file with the Highway Department: ye S (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. 0e!V12,JX S1 on &IJ 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 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. (O O�• �/ � F. Oficial Notice to public utilities-proof must be provided and TOTAL$ 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 SOU LD NEW Y RK ",I t' tJ 71(o/Z` Date Received by the Town Clerk Date Date Permit Issued 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 1 t •• t GENERAL CONDITIONS OF PERMIT APPLICATIONIPERMIT 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 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 perfonned 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 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. 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 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 pennission 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 DOT Construction Standards. V of 1 ' 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). 0�� �1�e1, ally) �, � � � � S®� ��eP ��- � � e� � `�" AC®® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 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 Partners Insurance Center NAME: Commercial Supp-ort 40 Marcus Drive (A/C,No. Ext); (631) 390-9700 (aC No_,(_631) 390_-9790 3rd Floor E-MAILE DSS: msmcertscm@epicbrokers.com Melville, NY 11747 - - INSURER(S)AFFORDING COVERAGE I NAIC It INSURER A:MERCHANTS PREFERRED INSURANCE —__12901 INSURED (631) 774-1379 INSURERB:Sutton Specialty Insurance Com 16848 R&R Construction Enterprises Inc. — -- - - INSURER C Fichter Brothers LLC INSURER 0: 282 Line Road 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 -ADDI�SUgR?. ..........----_..---'----- ---....._._...--._ LTR TYPE OF INSURANCE POLICY NUMBER ! MM/DOYYYYY i MM DDY EXP ?-- LIMITS A ` X COMMERCIAL GENERAL LIABILITY r 'EACH OCCURRENCE 'S 1,000,000 jDAMAGE rt0 RENTED —' — _ CLAIMS-MADEOCCUR : Y I CTRI008418 +04/20/2023 04/20/20241 PREMISES(Ea occurrence) j S 500,000 MED EXP(Any one person) i S 15,000 i REP SONAL&ADVINJURY�S _1,000,0_0_0 `EN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ _21000,000 POLICY j JE� L_LOC PRODUCTS-COMP/0P A 2,000,000 v OTHER: ; IEmpl Benefits Liabl$ 1,000,000 AUTOMOBILE LIABILITY I I i COMBINED SINGLE LIMIT S ANY AUTO I ; !(Ea U ° {BODILY LY INJURY(Per person)) $ F i OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ai AUTOS I i I _ °HIRED I NON-OWNED i I PROPERTY DAMAGE i AUTOS ONLY 1�AUTOS ONLY ;_(Per accident) . _ S S $ UMBRELLA LIAB R OCCUR { Y j IISCEX0300000283-01 01/12/2023:01/12/2024 EACH OCCURRENCE IS _ 3,000x000 X j EXCESS LIAB i I CLAIMS-MADE' j ( AGGREGATE I S 3,000,000 — (- —- —-...--- DED ' X I RETENTIONS 10,000 WORKERS COMPENSATION I ;PER 1OTH- �ANDEMPLOYERS'LIABILITY YIN ' { ! _ :STATUTE,)____._ ER__ jANYPROPRIETOR/PARTNERIEXECUTIVE ❑i N I A 1 !E.L.EACH ACCIDENT !$ ;OFFICER/MEMBEREXCLUDED? I --- ---- (Mandatory in NH) ` 1.E.L.DISEASE-EA EMPLOYEE S If yes.describe under !---- —1 ------ DESCRIPTION OF OPERATIONS below ! ! E.L.DISEASE-POLICY LIMIT:S i I IS I 1 I S DESCRIPTION OF OPERATIONS/LOCATIONS I 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 I Peconic, NY 11958w"H l ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page _ of _ R&RCONS-01 BOKULA CERTIFICATE OF LIABILITY INSURANCE DAT 51/16!216/2D02233 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 CONTAME:CT Rollin Becker N Inter-Insurance Agency Service PHONE Fax 380 N Broadway,Suite 400 Iwc,No,Ext):(516)352-7500 AIC,No): Jericho,NY 11753 E-MAIL .,backer@interinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:HARTFORD INSURANCE 30104 INSURED INSURERS: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. /NSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY YYP LTR INSD WVD POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAIMS-MADE r OCCUR DRAEAGE TO RENTMISES ccED S MED EXP(Any oneperson) S PERSONAL&ADV INJURY S 1"OTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREG TEPOLICY EJ JECT .7 LOC PRODUCTS-COMP/OP AGG .S S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S ANYAUTO BODILY INJURY Perperson) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ AUTOS ONLY AUTOS ONLY Perr. ,d.nt AMAGE S S UMBRELLA LIAB HOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE is DEO RETENTIONS S A WORKERS COMPENSATION X PER 0TH• AND EMPLOYERS'LIABILITY YIN STATUTE R ANY PR OPRIETORIPARTNEPJFXECUTIVE 12 WEC FX6968 1011/2022 10/1/2023 1,000,000 �FFICERIMEMBER EXCLUDED? ❑Y NIA E.L.EACH ACCIDENT S (Mandatory in NH) E.L.DISEASE-E4 EMPLOYEES 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 B Disability DBL175701 1/1/2023 111/2024 STATUTORY DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 ACCORDANCE WITH THE POLICY PROVISIONS. Peconic Lane Peconic,NY 11958 AUTHORIZED�REPPRREESSENTATIVVEo� J/V &CA ACORD 25(2016/03) ©1988`2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks ofACORD 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 Name: R&R, Construction Enterprises Inc. 282 Line Rd Manorville, NY 11949 Clerk ID: JENNIFER Internal ID: 1670