HomeMy WebLinkAboutMechanic St
,
Permit No.
olf
olK'
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765-3140
~
.:.- ../-/j_--it~~-t. 01---
r-EB ,,3 2000
("/0 F'G'1r
.t' ~ 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 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authoi'ized inspectors to mlake necessary inspections of the job site.
Print or Type
1)
6
CO.ci"
IV'I //73')
2)
IvA
Name' of Owner of Premises
Address
. ,
3) 5''0 . ,"j /.L.5 ""e j-
Work Description and
'01../7<, ,;J,; '" j? f/lt"c (f~' 5f,
Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? 'Yes_No )('
'If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
O1e~/17 Z:;L~' .
Signature of J\.pplicant
)-1/ /il{
Date'
5) a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation.
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)
7l
Tax Map: Section
Starting Date: 2/llofoo
, Block
, Lot
(Cfl/"'<-N"';) Completion Date J-l'7/:!()
8) Work Schedule:
Phase
Excavation........................................ .
Facility Installation.................................
Backfill & Compaction..............................
Pavement Replacement..............................
Under which authority is the application made: I/Jvsi){.::(
Estimated Cost of Proposed Work: $ :>. 500, eo.>
Remarks: ':J:."51c.//ulo r f......... (2 (VlO/,i1d.-:1' lA/el/
Completion Date
9)
10)
11)
(::'j S
~ ,.....~""\(.I{,vc,1<?r-
, '" L-/(?
1-; ql-; t-.,
rf? ("(,r'I'rP'cl
IV '/ 5 'DE L
D-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:JkrtR"ld ::1:",,)",<<,,<, (0.
b) Policy #:1.1 UEIM1~ Lj'>,/
c) State whether policy of certification on file with the Highway Depart-
ment: M()
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
1 3) Secu rity :
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
3 years
14)
Fees for applications and permits:
A 1. /Service Connections
--;;ro.-
A2. /Additional Excavations same service @ $10.00 = $
--;;ro.-
Basic Application Fee........ $25. 00
excavations @ $20.00 = $
B. Excavations 18" in depth or less:
0-100 I. f. = $10. 00
I. f. @ $0. 10 - $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I. f. = $30. 00
I . f. @ $0. 30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I. f. = $50. 00
I. f. @ $0.50 = $
Additional
E.
Utility Repair Excavations @$10.00 = $
No.
Repairs same service @ $5.00 = $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *
Authorization is hereby granted to the
issue a Highway Excavation ermit to:
in accordance with thiS' appl ation.
Town Clerk of the Town of Southold to
r
SUPERINTENDENT OF H IGHWA YS
TOWN OF SOUTHOLD, NEW YORK
~~~~
Raymond ~ Jacobs
r!:l-S-Oo
Date
Received by the Town Clerk ~/3j OiJ
ate
Permit Issued
02-/8;00
Date
Permit No.
rZf
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S
RECORD
I nspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(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 to repair
D-39
Page 3 of 3
,
RAYMOND L. JACOBS
Superintendent
DATE: ))/ j(} 0
TO:
CASE NUMBER:
Highway Department
Town of Southold
Peconic Lane
Peconic, N.Y. 11958
?lO /1S-
This is to notify you that New York Telephone Company
and Long Island Lighting Company have been notified in
respect to the application for an Excavation Permit in
the Town of Southold.
OJ2t~ '711 . ~~v,
Signature of the applicant
Tel. 765-3140
734-5211
North
W E
s
TOWN PARK.
SUPER MARKET
CHURCH
00 75
~
\~-
c
~O~
RESIDENTIAL
GRAPHIC SCALE
150
I
(INFEET)
1 inch ~ 75ft.
225
I
LEGEND
o
~
MONITORING WELL
PROPOSED
MONITORING "VELL
A HANDEX OF NEW YORK.
-
61 C CAROLYN BOULEVARD FARMINGDALE NEW YORK 11735
MOBIL BUSINESS RESOURCES CORP.
SERVICE STATION #I7-LL6
SOUTHOLD, NEW YORK
PROPOSED MONITORING WELL LOCATIONS
SCALE - 1" -75'
DRAWN BY - F.D.
JOBNO.- 12178
DATE - JANUAR 30,2000
RlclW6IJ
J:"EB. .3 2000
~
.,,.
HANoEX@
Practical Environmental Solutions
February 1,2000
Me. Raymond Jacobs
Town of Southold
Highway Department
POBox 178
Pcconic Lane
Peconic, NY 11958
Rc: Highway Excavation Permit
Dear Mr. Jacobs:
Handex of New Yark on behalf of ExxonMobil Corporation is requesting highway excavation permit for
the installation of two monitoring wells on the south side of East Mechanic Street in Southold. The
installation of the monitoring wells is at the request of the NYSDEC as part of a groundwater investigation
of a petroleum spill from the Mobil station located on Main Street See the attached site plan depicting the
location ofthc proposed monitoring wells. The monitoring wells will be finished t1ush at grade with 12-
inch diameter load bearing roadboxes anchored in 2-foot by 2-[00t concrete pads.
Attached please find a Highway Excavation Permit along with a copy of a certificate of insurance naming
the Town of Southold as an additional insured. Please advise me of the fee and bond or deposit
requirements. I will then forward to you the appropriate fees and bonds. The work is tentatively scheduled
for Febmary 16. 2000. If you require any other information, please contact me at (516) 752-7878.
Sincerely,
HANDEX OF NEW YORK
(.....,. ---
~"lt1it "
I, ' . f! l..cYv""'"
crt M. Tonn
Project Manager
Enc.
C: Karen Sottile (NYSDEC)
(jail Helfrick (ExxonMobil)
61 C Carolyn Blvd" Farmingdale, New York 11735. (516) 752-7878 . FAX (516) 752-7890
Fr.oM Belly Loker AI: Ron Sellers &. Associates. 'nc_ To: Albert Tonn
Fax#: (407) 999,9970 Date: 1125/00 09:39 AM Page 2 of 4
ACORD. CERTIFICATE OF LIABILITY INSURANCE OPIO BL I U,"TlOiMM!DDf{"1
HANDHOL 01/25/00
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ron Sellers . Associates, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
20 N. Orange Ave., Suite 702 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Orlando FL 32801
Phone: 407-999-9994 Fax: 407-999-9970 INSURERS AFFORDING COVERAGE
INSUR!::D ~_ Reliance National Indemnity CO
______,__",,_______________.,_H____,,____ -----.- -----.
INSUf;'ERB Hartford Insurance Co. -------
---,,--_.._- ---- - ----
Handex of New York Ir~suRER (; U S F . G
61C carolln 5l.vd. It,SUPEPD
,Farmingda e NY 11735 -~----- - .."-------
INSURE'RF
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLlCY PERIOD INDICATED_ NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONOITION 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSP T';'PE OF INSURANCE POLICY ~~UMBER :;~~C(M~~~~~E Pg~~\~~:6~;;!?'~ LIMITS
,~
~NERALLlA.8I1IT'i E,~,CHOCCURREi'ICE $1,000,000
B i-!- SM<:RUAL GEN.,PAL L~lur' 21 UERMS 4331 12/27/99 12/27/00 FIRE OIWAGE (At>yOM Tire) ,300,000
l__ CL/olMS MADE [i] OCCUR MEDE,<:p(Myoneperson:, $ 10, OO~".- H___
.----
i-!- l[CU Pf.,PSONJ;L.'!.;\JJ'/INJUP'( ,1,000,000
GENERAlAGGPEGATE ~_2,OOO,OOO
--.----- .'--- ._-,~"--- ~--_. n_ -
.~_~ll'L,AGGREGF;l1;::L1En I PPOO'JCTS - COMPiOP AGG i 2,000,000
---'-'. ---,,~ .------ --
pOLle, X JECT LOC
AUTOMOBILE LIABILITY COMBlrJED SltJGLE LIMIT
--. , 1,000,000
B l[ ,IlJJ'iAIfTCl 21 UERMS 4333 12/27/99 12/27/00 'Eaa~cllllmf'
- 'M'___ - .---.----
l- ALL Qir"NFf) ,~,UTO'~ BODILYII-lJURY
,
SCHEOLU:D A'_'105 ;P~'p~15Qr"'1
-- -,--- ------~.
i-!- HIREo"'un:;,s BDOIUIIJJUR','
,
i-!- NO~.f-O'NNF[) AUTOS (PBlaCci,jer,l)
- ------- PROPEPT'{ DAMAGE ,
rPe(3ccident'
fY" '""'UW ,"HTOONL\' EAACCIDENT ,
AniA'JTO OTHEPTH,~JI E,4,~,CC , .---.--..-
AUTOOt,JLY AGG ,
EACESSUABILlT', EACH QCCUPPENCE , 10,000,000
Xl OCCUR [J ClAIMS MADE n
C SUM 02005004400 12/27/99 12/27/00 AGGPEGA1E $ 10,000,000
.-. --.-
.
~~EDUC1l8LE ~-,~-,-,------
---- -. .-----
X PETE~fTlON :> -0- ,
V"OR~ERS (;OMPENs,olIOr.j ><NO I I ~;C;;~TL~~S I 10TH.
'"
B EMPl,OYFPS'll4RILlT'; 21 WBRMS 4330 12/27/99 12/27/00 , 100000.Q____
~~, EA.~~_":~crDENT
E L DISECASE. EA EMPLOYEE $ 1000000
lOt OISE"'Sf'_PClUCYLlMfT $ 1000000
OTHER
A PROF. POLLUTION* NTF 1632933-02 02/08/99 12/27/00 Each Occ. $10,000,000
ENVIRONMENTAL CONSULTANTS LIAB. Annrenate $10,000 000
DESCPIPTlON OF ':)PERATIONS!LOC,t;TION5.NEHlCLESfElo:CLUSlor-IS "ODED BY ENDORSEME~fTfSPEClo\L PPO\lSI0NS
Certificate holder's interest is refl.ected '"s Additional Insured with
respects to General. Liability for work performed on their behalf by named
insured. Re; Mobil. U7-LL6 (Main Ste . Youngs Ave. , Southold, NY) ; Project
# 612178
CERTIFICATE HOLDER IN T AODrnONAL INSuP'CD: 1~-ISl'RER LEiTE!';> CANCELLATION
TO'WNSOU SHOULD ;::.rTi OF THE ABOVE DESCPIBEO POLICIES Bf- CAt-Ie.ELLED BEFORE THE
fXPIRATION O/ITE THEREOF, 11-11" ISSUING INS'-'RER '/'illl ENDEAVOR TO MAlI.
Town of Southold 30 DAYS WRITTEN rJOTICE TC THE CfRTIFIc'''TE HOLDER NAMED TC THE
Highway Department -
PO Box 178, Peconic Lane LEFT. BUT FAILURE TO D':) SO SWoLL IMPOSE I-JO 08UG,,,nON OR Ll'ISILlT', 0>
peconic, NY 11958 ANY ".IND UPON ThE INSURER, ITS AGfNTS OR REP>'lESENTATl\lES
~L.~/~ /
AC R Co ,
o D 2S.S (7/97)
ACORD CORPORATION 1988
F.rOM: Belly Loker At Ron Sellers & Associates.nc. To: Albert Tonn
Faa: (407) 999.9970 Date: 1/25/00 09:39 AM Page 3 of 4
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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)
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25.S (7/97)
Fr.OM- Betty Loker AI- Ron Sellers & Associates. nc. To: Albert Tcnn
fa,. (407) 999.9970 Date 1/25/00 0939 AM Page 4 of 4
NOTEPAD:
INSURED'S NAME
Handex>of New York
HANDHOL
OP ID BL
PAGE 3
DATE 01./25/00
*Contractors Polluti.on Legal Liabi.lity is provided on an occurrence basis.