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HomeMy WebLinkAbout905 Willow Dr Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 09/08/23 Receipt#: 315149 Quantity Transactions Reference Subtotal 1 Excavation Permits 1683 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#9000244432 $550.00 PSEG, LI Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: PSEG, LI 117 Doctor's Path Riverhead, NY 11901 Clerk ID: JENNIFER Internal ID: 1683 79301t j,,t-to, 641-4 ,fid.bo Ylb Permit No. TOWN OF SOUTHOLD job ��� !�p 11 HIGHWAY DEPARTMENT 6M,^t IQ.j-� j . Peconic Lane (��6 Peconic New York 11958 0 tag P (631)765-3140 mod , 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 Applicant Phone Number Address of Applicant 2. Name of Contractor Phone Number Address of Contractor - 3. Name of Property Owner (je�uest Service(if applicable) Address of Owner 4. d ' i , JJ 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. 19 NOTE: All information requested by this Signa tu e 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 2 2 , Block S Lot 1 7. Starting Date: 17`is P0�3 Completion Date: 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: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ 11. Remarks: D-39 1 of 3 12. -Insurance Coverage: (Attach Copy) , (a) Insurance Company: ,IM •, � (b) Policy#:_ WA ,m ��b - 1�4+ (c)State whether policy of certification on file with the Highway Department: �Kf, (d)Coverage required extended to the Town: V 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. 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. J /Service Connections excavations @$50.00 $ ED,6 D No. A2. /Additional Excavations same service @$20.00 $ 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$ SSo Q(J 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. SUPERINTENDENT OF HIGHWAYS TO F,SO�lT L ,NEW YORK �AA� � Date Received by the Town Clerk 9 7 12-9 Date Date Permit Issued (I p l 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: Permit# Highway Department Engineer(with page 3)- ------- ----- Applicant Town Clerk (Original) - - - - -_ - -- ----LN-PER'S-RECORDS — - - - - -- - - - Inspection Date Findings (use code) Applicant Notified 1St 2nd -- 4t' (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 HIGHWAY--EXCAVATION AND REPAIR = L: Permitteels-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 permit, 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 mght:-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 Ifighway 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 terms and conditions of the permit or Chapter 237 of the Town Code. 4. Revocation of the Permit by the Hiahway 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 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 DOT Construction Standards. GENERAL, CONDITIONS OF PERMIT - - - _ - APPLICATION/PERMIT FOR HIGHWAY EXCAVATION ANIS 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 ddt used to backfill-any-excavation within-a Town Highway. 12. AllAreasof-Soil-Disturbance-.- All areas of soil disturbance resulting from the approved project shall be stabilized tothesatisfaction-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-deter-mined to be in-accordance with ASTMD 69&. Fill shall be_placed in maximum lifts of twelve (12")-inches thick and shall 5e 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). EW Workers' YORK CERTIFICATE OF STATE ola,Pensa�jort B0drt� NYS WORKERS'-COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Lon Island Electric Utility Servco LLC (800)490-0025 333-Earle Ovington Boulevard Uniondale NY 11553 1c.NYS Unemployment Insurance Employer Registration Number of Insured 51-11565 - - T Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security =certain-locationslhn Napo York-State,-ire._a Wrap-Up Policy) Number - - - 45-4652143 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) LM Insurance Corporation New York State Department of Transportation 3b.Policy Number of Entity Listed in Box"1 a" Traffic and Enggineeringg 250 Veterans Memorial Highway, Rm.6A-7 WA5-69D-463428-012 Hauppauge NY 11788 3c.Policy effective period 12/16/2022 to 12/16/2023 3d.The Proprietor,Partners or Executive Officers are ❑✓ included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A 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"2". 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 listed 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 contract of 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 holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that 1 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: Diane Beaudoin (Pri- ---- ----•-•insurance carrier) Approved by: -( - JQ(XU-6tiAZ) 12/19/2022 (Signature) (Date) Title: Sr.Customer Service Coordinator Telephone Number of authorized representative or licensed agent of insurance carrier: 401-248-9924 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov 71807826 1 9-463428 1 12/22-12/23 C105.2 (51-11565) 1 Erin Celing 1 12/19/2022 10:27:04 AM (CST) I Page 1 of 2 A ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/1612023 _ 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 - — REPRESENTATII/E_-OR:P-RODUCE_R,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). PRODIICER — --CONTACT MARSH USA,LLC. - -NAME: 1166 Avenue of the Americas-- pHCNr o Ext): 'C No): New York,NY 10036 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# -INSURER A:Associated Electric&Gas Insurance Services Limited 3190004 - INSURED -LONG ISLAND ELECTRIC UTILITY SERVCO LLC INSURER B:LM Insurance Corporation 33600 333 EARLE OVINGTON BLVD INSURER C:NIA N/A UNIONDALE,NY 11553 INSURERD: ---- - --- -- ---- - -- - - - - - - -- -- - ------ - INSURER E: INSURER F: _"""_COVERAGES _ __CERTIFICATE NUMBER: NYC-011006564-09 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED-BELOW HAVEBEEN 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 ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR D WVD POLICYNUMBER MMIDD/YYYY MMIDDIYYYY LIMITS COMMERCIALGENE_RALLIA8ILITY._____. EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence)- $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR XL5368110P 05/15/2023 05115/2024 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB HxCLAIMS-MADE - - - - - -—— - AGGREGATE $ 10,000,000 DED I X I RETENTION s3,000,000 $ B WORKERS COMPENSATION WA5-69D-463428-0121 1211612023 X I SPER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTE I I ER ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA ---- —(Mandatory-m-NH)— _ _ _ __ ___ E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION-OF OPERATIONS!_LOCATIONS/VEHICLES (ACORD I(111,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION New York State Department of SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Transportation Permit Section,Region 10 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Perry B.Duryea,Jr.State Office Building ACCORDANCE WITH THE POLICY PROVISIONS. 250 Veterans Memorial Highway Hauppauge,NY 11788 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Request for: TOWN OF SOUTHOLD DATE: 8/17/2023 PERMIT REQUIRED TO OPEN: THIS W.O. GUIDE DRILLS ON THE N/S OF WILLOW DR IN EAST MARION, FOR A DISTANCE OF 30' SOUTH TO THE PROPERTY LINE OF A NEW HOME AT 905 WILLOW DR. A 17" X 30" SPLICE BOX WILL BE INSTALLED ON THE WESTERN PROPERTY LINE IN THE PUBLIC GRASS AREA. GUIDE DRILL REQUIRES (2) 3'X3' DRILL PITS IN THE PAVED PUBLIC AREA (SEE SKETCH FOR DETAILS) Number of Road Openings: 1) In Grass Areas 1 2) In Roadway Areas 2 Approximate Start Date: 9/15/2023 Approximate Completion Date: 10/30/2023 PERMIT REQUESTED BY: GARY DUBOVICK DIVISION: EASTERN NOTIFICATION # 900000179714 TD 1300 TYPE OF ROAD: PAVED WORK ORDER# RETURN PERMIT TO: GARY.DUBOVICK@PSEG.COM X CONSTRUCTION DEPT. 1V PERMIT SKE'TCH JUI /uN 900000179714 C� V 3'X3' DRILL PIT PAVED AREA \ 3'X3' DRILL PIT 30' PAVED AREA WILLOW DR 17" X 30" � - - SPLICE BOX IN GRASS AREA ----- - - NEW 2-STORY HOME