HomeMy WebLinkAboutWillow Dr * * * RECEIPT * * *
Date: 06/19/14 Receipt#: 172396
Quantity Transactions Reference Subtotal
1 Excavation Permits 944 $181.00
Total Paid: $181.00
Notes:
Payment Type Amount Paid By
CK#2456 $181.00 American, Underground
Utilities/Cablevi
Name: American, Underground Utilities/Cablevision
P O Box 900
Eastport, NY 11941
Clerk ID: CAROLH Internal ID:944
Permit No. Iq Q
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958 10
(631)765-3140
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 the excavation 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
1. ,�mgQjrAA1 L1NoG72C-�OUNv Orn.»'jaS f D900 SAS?!'a2% N% 11q41
Name of Applicant GT1'` Phone Number Address of Applicant
2. 7:7'0 2 G��I,CSC l/1_Q0,k--
or Phone Number Address of Contractor
3. Ni'f
Name of Property Owner Requesting Service(if applicable) n Address of Owner f�
4. /LLC>N��r2/UE��S�s7�tJ 8c/C'L 2-491jL.,- ,
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 ofAhplicant
Application/Permit Form is �u� E 2-014
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 , Block Lot
7. Starting Date: 04 y —06 S� 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:_C!94&-J1S10w kEeA1/'Z-
See Town Code Chapter 237(E)- Provide Resolution by,or authority from,the Utility being modified.
00
10. Esti mated Cost of Proposed Work: $ , 000
11. Re marks: s,?AL1. 1s, LSC �9 G �N� 6x�r L AQL E � �SS/L E
D-39 1 of 3
12. Ins urance Coverage: (Attach Copy)
(a) 'Insurance Company: '7`'�-c A A-?v 1-0 C,Nte
(b) Policy#: 77 pf 10` 4 A 0:7 P A e, &21 Z 06—
(c)State whether policy of certification on file with the Highway Department: wL
(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$2,000,000 general aggregate.
13. Securit y: CA(gu V i i to L- goL�
(a)Surety Bond or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided: 2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee $150.00
At. /Service Connections excavations @$20.00 $
No.
A2. _ /Additional Excavations same service @$10.00 $
No. 1T�`
B. Excavations 18" in depth or less 310 o�
0-100 L.F.=$10.00;Additional 2, 1()'—L.F. @$0.10 $
C. Excavations 18" in depth to 5' in depth
0-100 L.F. =$30.00;Additional L.F.@$0.30 $
D. Excavations 5' in depth and over
0-100 L.F. =$50.00;Additional L.F. @$0.50 $
E. Utility Repair Excavations @$10.00 $
No.
Repairs same service @$5.00 $
Additional
of
TOTAL$ f ��
F. 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.
SUPERINT NDENT H HW YS
TOWN O UTH W ORK
zli� .4
Vi cent M. O lando
Date
Date Received by the Town Jerk
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
i
Copy Distribution: j
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk (Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
IA
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 for Repair
D-39 3 of 3
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r-rem: 06117/7014 lRtO7 *090 P.002/006
AC(7RIt� DATE{MM/DDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE F6/17/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIPICATE 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), AMORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. If the oertilkate holder Is an ADDITIONAL INSURED,the pofley(les)must be endorsed. N SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,conaln policies may require an endorsement, A statement on thle certificate does not confer rights 10 the
ceniflCete holder In Neu of such andorseme ■.
PRODUCER WNTAUT
A. J. Bonocore Agency Inc. 631 .236-5595
- - a�,49&3I—_ 3 -5920
1797-48 Veterans Memorial Highway L,MAIL
Islandia, NY 11749 s: INSURER(B)AFFOM G 00WRAGE "Aicr
INSURER A;TSCSNOLOGY INSURANCE CO
�INSURF.D American Underground Utilities Inc. INSURER D- r a a on re na a a, PA
P.O. Sox 900 INSURER C: ar a o�.e=ce Bn o uR ry na or,q,say
Sasutport, NY 11941 INSURER D:Zurich American znaurance Company
PH:325-1797;PAX:801-2831 MURER E:Hartor 171- a assurance Co.
631 714-0369 bill cell I INSURER F: W
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,
LTR TYPE OF INSURANCE POLICY NUMBER Y Y L+MITS
GENERAL LIABILITY EACH OCCURRENCE i 1,000,000
X COMMERCIAL GENERAL LIABILITY pptewlaes Es occurrence S 100 000
CIJUMS4AADE X OCCUR MED EXP ft one penes 1 5 000
A _-r �- TPPI014207 5/30/145/30/13 Peasomt.AADV IUURY s 1,000,000
GENERAL, AGOReGATe s_2,000,000
GIRL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG ,i 1,000,000
17
POLICY X PRO LOC =
AUTOMODLE LIAe1LITY -1.11 f 1,000,000__
X ANIYAUTO BODILY lWuRY(F'R pemon) S
A AUY008yyNEp s� $ULED TPP 1 0 X 4 2 0 7 5/30/145/30/15 BODILY INJURr(Per eeddanp s
HIRED AUTO$ AVTTO NON-OWNED s
S
7C UMBRELLA Lua ]C occuR EACH OCCURRENCE s 5,000,000
$ EXCESS LIAR 0.ArMS4A40t 86 015820104 5/30/145/30/15 AGGREGATE y S,000,000
DED X RETENTIO S 10,000 S
WORKERS COMPENSATION X IMI
AND EMPLOYERS LMU31LIlY
AFW M"6TQWARtNERenCUTN4 YIN E.L.EACI I ACCIDENT S .,000,000
C aa�s��e NN) ExauoEos ❑ "'" WC 005-81-5576
6/16/1416/16/15 - --"
yea E.1..rnalsASl:-F.A EMPLorE,s 1,000,000
DESCRIPTIO OF OPERATIONS bkm E.L.DISEASE-POLICY LIMIT S 1,000,000
D DISABILITY 5283378-001
8 DISABILITY LNY814925001 Di/Di/1412/31/14
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Altedr ACORD 10t,AEMtlonol Remarks Senadule,if more space Is mulred)
Projects Cableviaion Repair.
The Certificate Solder is Additional insured as their interest may appear.
CERTIFICATE HOLDER CANCELLATION
Torun of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
P.O. Box 1179 THIS EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
/��� •
01988-2010 ACORD CORPORATION.All rights reserved.
ACORD25(2010/05) The ACORD home and logo are registered marks of ACORD
5 /T L6LT5Z£T£9 TT40 punoabaepun u`120z.1911rV WV L5=S0 VTOZ-ST -unr
Frere' 06/17/2014 15;08 #090 P1003/006
STATE OF NF.W YORK
WORKMS'COMPPNSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER TBE NYS DISABILITY BENEFiTS LAW
PART 1. To be completed by DlsabilLtLBenefits Carrier or Licensed Insurance Agent of that Carrier
1 a. Legal Name and Address of insured(Use street address only) I b.Busin"'s Telephone Number of Insured
631315.1797
American Underground Int.
1',O,Box 900 lc.NYS Unemployment Insurant:e Employer Registration
Number of Insured
EAstport,N1' 11.441
1 d.Ftdural Emplvycr Identification Number of insured or
Social Security Number
13-4337136
2. Nance and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Being Listed as the Certificate Holder) Zurich American Insurance Co.
Town of Southold 3b,Policy Number of entity listed in box"la":
P.O.Box 11179 5283378-001
Southold,NY 11971
3c. Policy effective period:
4.Policy covers:
a.X All of the employer's employees eligible•under the New York Disability Benefits Law
b.C1 Only the following class or classes of the employer's employccs;
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 NYS Disability Benefits insurance coverage as described above,
Date Signed 0AWLL4_ By____ ---- _.., _......._..„...»»,.,•---
($1panurc ofinsuruice carrier's suthtxized mprescatative or NYS Licensed Insurance Agent ofthat insunsneo carnet)
TelephoneNutubtr_631 234-5595 Title _ Secretary/Treasursr __
IMPORTANT; it box'4a'h checked,and this form is algned by the inanrsate carrier's autherixed representative or!NYS Licensed Insurance Agent of that
carrier,this oerillWale Is COMPLETE, Mall It directly to the certificate holder.
IF box-011 is checked,this eer0ficute is NOT COMPLETE for po rpotes o(Seetion 220,Subd.8 or the Disability Benefits Low.It must be maned
for rom letloa to the 11r„erkers�Com asalion hoard.UR htana heacntehee tiniti 2R Mrk Street,Albany,l\ew 1'nrk 12207,,_ _ ___
PART 2. To be completed by NYS Workers' Compensation Board(Only If box"01'of fart 1 has been checked
— State Of New York i
Workers' Compensation Board
According to information maintained by the NYS Workers'C:ompcnS1tion Rourd,the above-pained employer tins complied wish the NYS
Ditubility Benefits Law with reVLci to oil ofhis.4ter employees,
Date Signed.:.....,..._.._ »..,.,.,. ..»
tSignaturc of NYS workers'Compchisation RtMrd rnlpioycei
,1
Telephone
Please Note:On1v insurance carriers licensed in it-rile N)'S disabdily benefits insurancepolkies and NYS licensed inm4rance agents of
Those insuranre carriers are ouihar•ized it)issue Form DB426.1. Insurance brokers are NOT authorized to issue(his form.
DB-120.1 i5.06) i
S /Z 'aDva L6LTSZETC9 TTgII punoaf)a9puf1 u>;oia9uiV KV SS:SO bTOZ'ST -unf
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 Exceedine One Hundred (1001)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).
' r
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).
s�ly