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Home My WebLink About4735 Cox LnPermit No. /0 / TOWN OF SOUTHOLD � Ffkt -N HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958 `e (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 Type 1. Z;rn es /G X, (e1/ SIG - FIF - V 7.)- Illi ll l iifJ Name of Applicant Phone Number Address of Applicant 2. J; /1 .Lon<. 4,y/ TAC G3/-.2P3-A0.9".2s-o7 &T - Name of Contractor Phone Number Address of G 3. 9 A4 ,nWs F4 73, N e of Property Owner Requesting Sgrvic�e�(if applicable) Q�ddress of ee f ^� _ / 4 `,die �Y e t 0735 S/ ever '� Q Cie. /vim lin e,. )0-1 GL 4. to A0:1 Ae A,e -rap o LR 4 a Al. "44 -r LIQ12 Work Description and tocation (Street Number, Hamlet, Cross Street) (a) Is construction located within 75 feet of tidal wetlands? * Yes No x *If yes, other Town permits may be required. f -r NOTE: All information requested by this Sign of Applicant Application / Permit Form is J /, 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 02 , Lot /4.1 7. Starting Date: //O /l S Completion Date: 8. Work Schedule: Phase Coml2letion Date Excavation Work Schedule Facility Installation i _ Must be provided Backfill & Completion _ for consideration as a Pavement Replacement _ I7/ 4 A5 _ Complete Application. 9. Under which authority is application being made: L 4p/7 p See Town Code Chapter 237 (E) - Provide Resolution by, or authority from, the Utility being modified. 10. Esti mated Cost of Proposed Work: $ C/ UVU, O6 11. Re marks:l 00 pL�f f�Li t JAI-IPz/ vhJer .OaYe-61 l'D4r, Gu � y4) Ac.r JIF ave D -A 1 of 3 s'//q i2. Ins urance Coverage: (Attach Copy) (a) Insurance Company: Z--r1*p Thdurctxc--- C6, (b) Policy #: Q Z/4? S 9,s00 1�4C k Y (c) State whether policy of certification on file with the Highway Department: /Vo (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: (a) Surety Bond or Certified Check provided in the total Amount of $ (b) Maintenance Bond provided: 14. Fees for Applications and permits: Al A2 B. C. D. E. Basic Application Fee 2 years or /Service Connections excavations @ $20.00 No. / Additional Excavations same service @ $10.00 Excavations 18" in depth or less 0-100 L.F. = $10.00; Additional Excavations 18" in depth to 5' in depth 0-100 L.F. = $30.00; Additional Excavations 5' in depth and over 0-100 L.F. = $50.00; Additional 3 years. $150.00 $ 2,0, 0 0 L.F. @ $0.10 $ L.F.@ $0.30 $ L.F. @ $0.50 $ Utility Repair Excavations @ $10.00 Repairs same service @ $5.00 It It TOTAL$ 1762, 00 F. Notice to public utilities proof must be provided and Clt Se �� CO Sof 3 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. SUPERINTE ENT OF HI HW rYSSTOWN OF UTjHOLD, W O Vi nt"k Orlando Date Date Received by the Town Clerk �� U .� Date Permit Issued /10 t' 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 s// y Copy Distribution: Highway Department Engineer (with page 3) Applicant Town Clerk (Original) St 2nd 3 rd IB IL ST UTM BUC WIP DB HFS RFR D-39 Inspection Date INSPECTOR'S RECORDS Findings (use code) REMARKS CODE Improper Barricades Improper Lights Sunken Trench or Excavation Unable to Measure (due to backfilling) Building Under Construction Work In Progress Improper Backfill (too high, not sufficient) Inspector Holding for Final Settlement of Excavation Ready for Repair Permit # Applicant Notified (To Permit Clerk) 3 of 3 s)1V GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. 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 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 Rieht 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. 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, 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 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. 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 (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). sJ l� JAM Long Island, Inc. P O Box 2507 (631) 287-0580 Southampton, NY 11969 283-5898 fd Cat( Lei \ \ ,fer✓iGQ hC/'Q �I 3 3 CGx L 01/26/2015 00:23 #7157 P.001 /001 TE OF LIABILITY WS ERTIFICA URANCE 11/17M4 THIS ornRrir-icA-rI:,*(S,I i6EDA&.91MA-Trm or INFORMATION ONLY:AND CONFMS NORZIGHTS UPON THE dERTIFICATIE, 14OLDER, Tin GERTIFJWE DOES NOT AlilROATIVELY OR NEGATWELY AMEND,,, ExTENci,,(W ALTr=R THE CbVERA10E.AWORDEE) By Tarl'burs ci BELOW. THIS. CERTIFICATE OF INWRANCE DOES NOTr CONSTITUTE A CONTRACT BETWEEN THE ISSUING:' INSURER(S), AUTHMIZED REPRESAWTATM OR PRODUCERAND THE CERTIFICATE HOLOM IMPORTANT: If she certificate hoiddrits AnAWITIONALINSURED, the policy(feOmust, -be endorsed. tf:SUBROGATION)SWA-NFD,subjili-to- the jtqtTyn$ &fkd t*r41t1.Mr Of the policy;: 'o . I JjLyLj�efjAtn poficift reqvjire.awendorsemeot A: statemept omthis certnIcate ooes.notomw 6grft to the *orrificate holder in lieu otsuch "WorsornejWs� moDurpmQQXTAQ7 NAME- Mirftl lrwwanoe'p.rctxci n Team I?kCCT16E 388 gr, AIL jAr- No), . (5351388:Aa31 RF 27CO 0MWoo0�.AVe-,50K0 E� ADD 3. Rodvsfgr, NY 148q'6 rN5URER(5y!6PFOR1D.f'6f.G COVERAGE NAJv Phvnp (SM 39"53Q Fax (585) 38a953t IN3URER A: erie ln-u-n6a Co. Po BoX 2507 INWRER D,: toohhompton, NY`I tq.69. lxsulieR E: 114SUREtR F! COVERAGES CERMCATIEWUMBER: REVFSJON NUMMR-. THIS: IS TO•10ERTfrY-'rHA-.rTt1E PQUCJES OF WSUPA14CE USTEDZELOW.11AVE 611!N WUF-D.TO'THE INSURED NAMED ASOVI! 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PM cOW/.op ACG s 2,000,Dw.w AUTOMINLE (:LABILITY .tt12D rINGIJ=- LfMfT s AkJY,ALrrO A A" OWNED SCH2DULM AUTOS �MGD AUTOSS NED TI 0 12-S940012 1�2J09/2014 12/09/.2915 50"Ly UMS tELLA LLAa OOCUR EACH�QCCURRENCE s 1,000,0W.00 A t. mKoms-LIA3 ED CIAM,-MADE �77-,---" low -0-1 DED W m7r�10N:$ 10 0 12(09/2014 I 12togr2pi 5 . AGGPE,:GAT2 t 1,000,000.00 - -- s 1, . ...... E].V.0STATU- D.(YrH-1 P�L.V-ACq.A=ENT 5 0-=� WgRkER$OONPENSAT16K A14P EMPLOYERS UAMLrrY Y ANY PRopmei-6�vvexscunyr= OFFPCERNEW12ER GXCLUDM1 r---ijN?A Ltmrr I s ft DESCRIPTION OF.OT pS"..ViLti Remarks If I LOCATION Bulgin a As. -Wates Inc At, all contracted looatiorty -thO owner, Contractorarid 199 niarirvL�r-LLC'(a�sc�onstuc�ti6h inarog&)As named as.AddjIjWW InsuredWith respects tothe 'Gereraj.��i*. oove'age- CERTIFICATE HOLDER Town:of Soutold po Box 17g Pemrfici NY 1.1,958 AGORD 26 (2010105)OF TION SHOULD ANY OF THEABOYri OESCRISM POLICIES BE CANCELLED, BEFORE 'TKrz exmRA-rioN DATE THEREOF, NOTIC EVVILL BE DELIVERED IN At-COPPANCE-VITH THE POLICY PROVIVONS: AW14(�FUZEb REPRESEUTATNE: (�D 19M.2010 ACORD.C.ORPORATION. All rights reserved. The.ACOFZD;name ,and :logo ;are,'regittered. marks of ACORD