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HomeMy WebLinkAbout5295 Bridge Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 10/19/23 Receipt#: 315783 Quantity Transactions Reference Subtotal 1 Excavation Permits 1689 $1,520.00 Total Paid: $1,520.00. Notes: Payment Type Amount Paid By CK#3510 $1,520.00 Marrcon, Development Corp Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 1 Name: Marrcon, Development Corp Po Box 486 Glenwood Landing, NY 11547 Clerk ID: JENNIFER Internal ID: 1689 Permit No. l (-A U ` TOWN OF SOUTHOLD RECEIVED HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958 OCT 1 9 2023 (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Southold Town Clerk 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 / 6 44--N.7-A(e o 00 /74.4 r.)m A'-'- -5 .& G!Tj �;' 16-77 Name of Applicant /p1 � Phone Number Address of Applicant /� 2. r7AI/Y.o/(' de�/�Dn (.V/� l�l��e�-3`�7�/oa T O, 3,� �d'V f!J1eyab-d bw-,4t ci, i" / Name of Contractor Plione Number Address of Contractor /���� � 3. '52� jr(6(e4f I SGC 71 1z" y�/e,rUe Set L(i� A l 11519 Name of Proper Own//er Requesting Service(if applicable) Address of Owner n 4. 0&d O�e q -f'or' a%eA-'ea.e seeviee Qf- -6-2,95- yf,dje Gate. (amu-o q Ue lJ`�/��35, 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 Signature of Applicant Application/Permit Form is Required for a complete application! ZO/ e ,023 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 perinits 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 gq, Block 0 Lot 6, /(.0 7. Starting Date: //-/7-0 Z? Completion Date: 13 8. 8. Work Schedule: Phase Com letion Date Excavation �O a?, Work Schedule Facility Installation i 702-1 Must be provided Backfill &Completion SOTS for consideration as a Pavement Replacement 1-4 17,-4 3 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: $~,r' O00 �II r 11. Remarks: 7fP Y�_ DY. YL D-39 1 of 5 12. Insurance Coverage:(Attach Copy) / /1 (a) Insurance Company: pp L—V4P?677� l/js u.Aa rrt e.• (b) Policy#: /-.60003343 (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$2,000,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ fib)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. 2 /Service Connections excavations @$50.00 $ /00 No. A2. /Additional Excavations same service @$20.00 $ 2� No. B. Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; /VIA' L.F.@$10.00 $ AIA C. Trench Excavations 18"in depth to 5' in depth Total Lineal Footage of Excavation; —")0' L.F.@$30.00 $ Foo D. Trench Excavations 5'in depth and over � Total Lineal Footage of Excavation; `,/�L.F.@$50.00 $ A/4' E. 0 Utility Repair Excavations @$1,000.00/Each $ -114 No. O - Additional Repairs of Same Service @$500.00/Each $ No. TOTAL$ F. Official Notice to public utilities- roof must be provided and —7 P P 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 UTH LD,NEW YORK iel J. Goodwin - 1 Date Date Received by the Town Clerk Date Permit Issued l o y Z Permit No. 1 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 S Copy Distribution: G� Permit# I Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1 St 2 nd 3rd 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 GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR I. 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 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 pen-nit 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 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. `t 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; d) 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). 4 (del, aJIS) A C�® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/04!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 Dan Waldeck NAME: The Liberty Insurance Brokers d/b/a The Budde Agency alc°NNo Ext): (631)264-0579 (A No 16 Riverside Avenue E-MAIL dan@buddeinsurance.com ADDRESS: Lic#OD79653 INSURER(S)AFFORDING COVERAGE NAIC# Amityville NY 11701 INSURERA: Evanston Insurance Co 35378 INSURED INSURER B Marrcon Development Corp. INSURER C: 137 Glenwood Rd INSURER D: INSURER E: Glenwood Landing NY 11547 INSURER F: COVERAGES CERTIFICATE NUMBER: 23-24 GL REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 POLICY EFF POLICY EXP LTR INSD WVD POLICYNUMBER MMIDDIYYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OMINNJURY $ 1,000,000 CLAIMS-MADE �OCCUR PREMISe $ 300,000 MED EXn) $ 5,000 A MKLV1PBC003343 04/13/2023 04/13/2024 PERSONY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERA $ 2,000,000 POLICY PRO ❑LOC PRODUCTS-COMP/OP AGG $ 2.000,000 JECT OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO 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 EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEElNIA E.L.EACH ACCIDENT $ OFFICEMMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is included as Additional Insured as required 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. Highway Department 275 Peconic Lane AUTHORIZED REPRESENTATIVE Peconic NY 11958 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYS I F New York State Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE D. •.r .D ^A^A^A 825376356 MARRCON DEVELOPMENT CORP. P O BOX 486 . GLENWOOD LANDING NY 11547 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER MARRCON DEVELOPMENT CORP. TOWN OF SOUTHOLD P O BOX 486 HIGHWAY DEPT. GLENWOOD LANDING NY 11547 275 PECONIC LANE PECONIC NY 11958 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2449 442-9 782827 07/13/2023 TO 07/13/2024 10/4/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 442-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT DANIEL MARRA MARRCON DEVELOPMENT CORP A ONE-PERSON CORPORATION THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. 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