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HomeMy WebLinkAboutNew Suffolk Rd Town of Southold P.O Box 1179 Southold, NY 11971 f * * * RECEIPT * * * Date: 07/11/24 Receipt#: 332637 Quantity Transactions Reference Subtotal 1 Excavation Permits 1734 $0.00 Total Paid: $0.00 Notes: ! Payment Type Amount Paid By Southold Town Clerk's Office I 53095 Main Road, PO Box 1179 J Southold, NY 11971 j I � I Name: Cutchogue, Fire Department 260 New Suffolk Avenue Cutchogue, NY 11935 Clerk ID: LYNDAR Internal ID: 1734 Permit No. RECEIVED TOWN OF SOUTHOLD �SUFFOic HIGHWAY DEPARTMENT Peconic Lane JUL to Peconic,New York 11958 0 , (631)765-3140 y ate. - Southold Town CI 1 , 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 I Cutchogue Fire District 631-734-6907 :,260 New Suffolk Road,Cutchogue, New York 11935 Name of Applicant Phone Number Address of Applicant 2. Stalco Construction, Inc. 681-254-6767 1316 Motor Parkway, Islandia,New York 11749 Name of Contractor Phone Number I Address of Contractor 3 Cutchogue Fire District '260 New Suffolk Road, Cutchogue, New York 11935 Name of Property Owner Requesting Service(if applicable) :'Address of Owner Road opening and restoration for subject site storm water system underground pipe crossing New Suffolk Road at subject site frontage 4, to drainage structures located on commonly owned land: Cross street:Main Road,AKA NYS Route 25. Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction•located within 75 feet of tidal wetlands? * s No X *If yes,other Town permits may be required. NOTE: All information requested by this i ature of Applicant Application/Permit Form is 7_ �� �,/ kequired for a complete application! i 7` j 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 102 Block 06 Lot 05 7. Starting Date: 7/2/2024 Completion Date: TBD 8. Work Schedule: Phase Completion Date Excavation 7/2/2024(need road closed). Work Schedule Facility Installation 7/2/2024(need road closed)' Must be provided Backfill&Completion 7/2/2024(need road closed) for consideration as a Pavement Replacement TBD-Mid-Late August if allowed Complete Application. (will not need road closed) 9. Under which authority is application being made: Private Storm Water system. (A Public Utility is not involved.) See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ 30,000-40,000 11. Remarks: We can pave the road sooner, but superintendent prefers letting it compact over time.We also would like to wait until our concrete sub is back on site to pave. D-39 1 of .3 i 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: Valley Forge Insurance Co. (b) Policy#: 7015379257 (c)State whether policy of certification on file with the Highway Department: Attached with this permit application . (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$2,000,000 general aggregate.. 13. Security: (a)Surety Bond X or Certified Check provided in the total Amount of$ $9,950,000.00 (b)Maintenance Bond provided: X 2 years or 3 years. 14. Fees for Road Opening Applications and permits: I 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. i A2. /Additional Excavations same service @$20.00 $ No. B. Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; s 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; .55 L.F.@$50.00 $ 2,750.00 E. Utility Repair Excavations @•$,1,000.00/Each $ No. Additional Repairs of Same Service @$500.00/Each $ No. f F.. . Official Notice to public utilities_-proof must lie provided and Shall be attached to this application prior to issuance,,of permit. 15. Fees for New or Alteration to Curb Cut: Basic Application Fee - $50.00 A Curb Cut would include any new or alteration of an existing driveway within the boundary of the right of way. The configuration of such is to the conditions set forth in Chapter 237 of town code. ! TOTAL$ 3 Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: i in accordance with this application and subject to the"General Conditions"and;"Special Conditions"of permit(if any)attached hereto. I SUPERINTENDENT OF HIGHWAYS TOWN OF,8WTHOLD,NEW YORK Dani 1 J.Goodwin ^ Date Date Received by the Town Clerk ' 1 U 'of LI Date Permit Issued rl ' 11 Permit No. 1 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 3 j Copy Distribution:, "j l Permit# I Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 1 St + i 2nd i 3rd 4th (To Permit Clerk) i REMARKS i i . I 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 ' e , DATE(MMIOD/YYYY) ACOO ® CERTIFICATE OF LIABILITY INSURANCE 06/25/2024 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 CONTACT Christine Schuller NAME: AssuredPartners Northeast,LLC. PHONE (631)465-4000 FAX A/C No Ext: A/C,No 100 Baylis Road E-MAIL Chris.schuller@assuredpartners.com ADDRESS: Suite 300 1NSURER(S)AFFORDING COVERAGE NAIC# Melville NY 11747 INSURERA: Nat'l Fire Ins.Co.of Hartford 20478 INSURED INSURER B: Continental Casualty Company 20443 STALCO CONSTRUCTION INC.. INSURER C: Continental Insurance Co. 35289 1316 MOTOR PKWY INSURER D: American Cas.Co.of Reading 20427 INSURER E: Philadelphia Indemnity Insurance Co. 18058 ISLANDIA NY 11749 INSURER F: .Westchester Surplus Lines Ins.Co. 10172 COVERAGES CERTIFICATE NUMBER: '24-25• 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LIMBS LTR INSD WVD POLICY NUMBER MMIDD MMIDD COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ 2,000,000 DAMAGE O RENTED 10011�0 CWMS-MADE'r OCCUR PREMISES Ea occurrence $ X Contractual Liability MED EXP(Any one person) $ 15,000 A X XCU included 7015379257 02/01/2024 02/01/2025 PERSONAL&ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY JEST LOC, PRODUCTS-COMP/OPAGG $ .4,000,000 OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED AUTOS ONLY AUTOS 7015379260 02/01/2024 02/01/2025 BODILY INJURY(Per accident) $ HIRED NON-OWNED .• PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB CLAIMS-MADE 7015379274 02/01/2024 02/01/2025 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY Y./N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ D OFFICER/MEMBEREXCLUE N N/A 7017815909 02/01/2024 02/01/2025 (Mandatory in 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 $ Excess Liability 4 x 5 E PHUB898816 02/01/2024 02/01/2025 4Mill/4Mill DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) The following are included as additional.insured if required by written contract subject to the terms and conditions of the stated policies: Town of Southold Highway Department General Liability,auto,and umbrella coverage apply on a primary and non-contributory basis,with a waiver of subrogation in favor of additional insured's 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 Highway Department ACCORDANCE WITH THE POLICY PROVISIONS. Peconic Lane AUTHORIZED REPRESENTATIVE Peconic NY 11958 .9. A-- @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r AGENCY CUSTOMER ID: j LOC#: . AC40R Di ADDITIONAL REMARKS SCHEDULE Page of i AGENCY i NAMEDINSURED AssuredPartners Northeast,LLC. STALCO CONSTRUCTION INC. POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes Insurer(F)Westchester Surplus Lines Ins.NAIC#10172 Policy#G70969075 005 Practice Pollution Liability$2,000,000 Occurrence/$2,000,000 Aggregate 1 OK Retention Effective 02/01/2024 to 02/01/2025 Insurer(G)Hartford Fire Insurance Company NAIC#19682 Policy#12UUMBJ2176 Blanket Leased Equipment$250,000 Effective 04/02/2023 to 04/02/2024 Insurer(H)Admiral Insurance Company NAIC#24856 Policy#DEP1639325P7 Employment Practices Liability limit$1,000,000 effective 02/01/2024 to 02/01/2025 I i I 1 j 1 ' r 1 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i