HomeMy WebLinkAbout455 Woodside Ln Permit No. ( 10 3
TOWN OF SOUTHOLD '�s
'' OFFOL4.
HIGHWAY DEPARTMENT ;'... ‘ss
Peconic Lane 3
Peconic,New York 11958 4,'
(631)765-3140 • o.A 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 Type
l. C41 U1�S2OAV 4 Ut€4 e, 7D0 sok /099. &lova{ NY um'
Name of Applicant Phone Number Address of Applicant
2. 631 '/31 -T14.0 �n Gam, 63/ -260 •3k53
Name of Contractor Phone Number A ess of Contractor
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. /feet O/KL GC- advikk 'S-s woods, /see CatG(Attt Q9t
)
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. /� - .
I, /.i IJ
NOTE: All information requested by this if Signature of Applicant
Application/Permit Form is
Required for a complete application! jl X7(0
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
l 1 2/7/ZoF
7. Starting Date: � � 2 0�� Completion Date: (o
8. Work Schedule: Phase Completion Date
Excavation All GvoY'h CA,iU be- Work Schedule
Facility Installation Stab-fed runt coy/tied Must be provided
Backfill&Completion Sam dam.. for consideration as a
Pavement Replacement r 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: $
11. Remarks: . i221i, es atyi_el Ate,nd -0-6
et X1.4-e-
D.39 U W ctei 3 14/4-0c raai s l-G-e- /v D-�f t vet/6-e 1 of 3
114 h e..�,e�,m tr-�/.r�'he
•
12. Insurance Coverage:(Attach Copy) •
(a) Insurance Company:
(b) Policy#:
(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$2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided: 2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee for Each Project Location - $150.00
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 @$20.00 $ 240 b• CM,
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18"in depth or less / •
0-100 L.F.=$10.00;Additional '7 L.F.@$0.10 $ 5C.e-D
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
TOTALS 2 2 6 . So
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 wi
this application and subject to the"General Conditions"and"Special Conditions"of permit(if: y)attached here f.
SUPERINTE II ' •• ill here
TOWN OF SO H•''a rf
IRK ,
,
Vi ent . •rland()
19,
(t(_ DateDate Received by the Town Jerk 1 K�
Date Permit Issued '�9\I t Permit No. I � d
� 3 .
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
- 1 , i , d ._ , 1,
7,-A/es
Pox /09..g
6,5( `tL3 -7,e6
0911&t. 6 aw_A
5/ ,_ o -5'53
E-A6L: AJEs r c.�
_ O
+— Ira
W
z �
1
I
-
lnJOODSIDE LN
Lt55
I
•
'
e CERTIFICATE.OF LIABILITY INSURANCE 1/11/2016 '
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 be endorsed. If SUBROGATION IS WAIVED, subject to
the temis 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 I CONTACTMichael Bonocore
NAME:,,
A. J. Bonocore Agency Inc. PHONE Fes, 631-234-5595 If�AR "°I"631-24-5920
1797-48 Veterans Memorial Highway
Island.ia, NY 11749 ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC 0
INSURER A. Technology Insurance Company
INSURED CDL Underground Specialists Inc. INSURER B.Ace American Insurance Co.
PO Box 1098 INSURER C,Nat'1 Liability 6 Fire Insurance Co
Commack, NY 11725 INSURER D.The First Rehabilitation Life
INSURER E
INSURER F.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDmONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILISR TYPE OF INSURANCE IINBD buds-
1.712 POLICY NUMBER I1(MMN/UDCYO VY1 (M�M/DCD%'YYY1 UMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
l CLAIMS-MADE ®OCCUR PPR M SES Eat
— occurrence) S 100,000
%CONTRACTUAL MED EXP(Any one person) S 5.000
A B XCU INCLUDED X Y TPP1014104 4/19/15.4/19/19 PERSONAL 8.ADV INJURY s 1,000,000
GEML AGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE ,j2,000,000
POUCY®JECT ®LOC P�QUCTS-COMP/OP AGG $ 2,000,000
$
OTHER: S
AUU.OMOBILEUABIUTY COMBINED ISINGLE LIMIT $ 1,000,000
fEe X ANYAUTO BODILY INJURY(Per person) $
ALL OWNED i SCHEDULED TPP1014104 4/19/154/19/16 — —
r_ BODILY INJURY(Per accident) $
A NON-OWNED PROPERTY DAMAGE
AUTOS (Per accident) $
HIRED AUTOS
g $1,pop cors. X 1,000 COMP $
X UMBRELLA UAS lX,OCCUR EACH OCCURRENCE $ 5,000,000
—, N10837327 4/19/15.4/19/16
B EXCESS UAB CLAIMS-MADE AGGREGATE $ 5,000,000
_DED I I RETENTION S S
WORKERS COMPENSATIONI STATUTE I I ER"
AND EMPLOYERS'LIABILITY y��
C ANY PROPRIET /PARTNER/XECUTIVE �1 N!A E.L EACH ACCIDENT $ 1,000,000
OFFI(Mandatory In NH) 1`11 V9WC661423 8/26/158/26/16 EL DISEASE-EA EMPLOYEE $ 1,000,000
If mss,describe under 1,000,000
EL OF OPERATIONS below L DISEASE-POLICY LIMIT S
D Disability D184558 7/17/15/7/16/16
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
Replace damaged cable in the Town of Southold.
Certificate Holder is Additional Insured as their interest may appear.
CERTIFICATE HOLDER CANCELLATION
Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
53095 Route.25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
P.O. Box 1179
Southold, New York 11971 AUTHORIZED REPRESENTATIVE
®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
.‘,47;,.,;,::;51.,?(,:•S;',j'Al,r .1.;,,.;Vc...1:::,',i-D r,!;.1.1.:Si:C;;r...ifiC,:1-IA;V..,1'.c,(....E.10,1.11!;:ii-Vi.‘ li vcolic:
(..:•rit0P-50 i 4 !CCD;:'..1i,::7,0i5'./.1.1r;.'ii ',-,!i of i):'.I e;•!eim.;(4
i-s,<,,i1,:..,-.:.•..,c,),:•:-..,z--,:::--,, .-.-— ...
,... .
e°nCY°1-C1'1
( 4
;431io=r Traar 1 t 1,lc'""'...'.: .".:1••.-Y'1;0 1`.1.1.; V 4
TTAD
1 2:4();)2 if°1-•4"%j 2 1 ,,,-.., i.:",•,i,.••• ,,,• ....-..,.;- .,.. •
Ii
1 ,1,'0 47.7 0 T. 2,-..lacpop.-1 z •,-,4••,-,-.. --.,„,.. ..,,..J.,,.: -,,,-...-.•,%;.•,..-. i•-••.:,--0 t_:c..,.. ....i..,...i,r', 1E;
i
i
L;,:!:il'tjt1;t-Lt".. 1.0..,i i.'•-•C;"` V;inti R.:::i V 1.101.i
i
' 1
J 11
i I
...
ICC'T—pTta:Cqp0 Horcio= Tv.; vc5qT.pTovv) Iuanxoq zo cp6Tr Tu.ptc-tec Itn-strX ubbeex- t
, 9
w
luctrracc quu-tutat.:q clpro Tu cpc xomu cr; Eoncporg
_. ..... ::::,,,,-.3-e.,i- -t3e,. . ,, I.
1
r.--r--........---,-........—..---.--.. .-.......--..............,..--..-.4.4.—‘,......--...........,---,...-...•,....-
i
? I
t D i DT2oPTI '4::2`t• ' I I DT..,r-' ,12 8
( 1
c-- T--
i.-r7---,:-...--'-'7".”1-.7:77••••7:7-4,:. .,....,.....„,,,,,,....*„....4
1 RI.414---V18--*-11 1 IADNCePrqn2 t \5e\T2i13\5e\TP4,2-,:_-'- ' -""- 1- T goo 'o00 )•
1 c 1, ..r., .,-, ... ,,..,,.:,•,• ... ... i ;.,„ ,•••• _.,.—....._„........__....,..4„_—...._ __.....
'
i - '"- ' '• ' -- - • • '-- 41 i
1 "
• , j t
--1--'-' --.
t LI_...'1....J._....-_,...,.. ....._ -
___A $ t
t E i I: ., •r i r , ,.i.: .-... - 1 : t
7-:-_-•.71 ,, . ! 'i i'..P11083.13:3..1 •.- y? sp gs.0 ,.
11\Ta\IZI\T8\Ttr----------,,-------1-v--- •--- ----i
......-.• .,:- , t. (,.•
„. .1_- 3 _ „ _ _ & _
i — 1,,-,;: , • - , rr Txt-'0,,,, ,...-,,z, t i t I z -f1 t
i 1----1, ;-_,,,,, - $---1 •-,-, , f
,i . .., .. ., ,. .,•
I
te........4'•' '''''•'' 1 / E,Ial'OTITOK;
iN7\7a\3'2i1\76\Tev7------------Jr.----------------1
, .
11
.r A .',.i •L'-',• ''
'4-4-...1,...... 1 .........--‘ .-...•-• ............--.....*--J.......,...........--..',....., ...- ' • ''. 'c';' ::f;.•'.--,-,1-..-.2::CIP-0-‘.0,g-0 ''
k R
i A'-''''';t '••t" Nil :--1- ril. -.., I 1 . 1
;
t i,,,,... -• t I.. V 'j 1 i t
c 1 1
f.. ,7....'t,.17"./77,7: ''''''6:L'
- - - l ' 5'000 000 ;
x i 74. j
,;.,i„Iri : '. r7r. .4:7':4,::7,:..,::::'-.1.' )4 1"
; •-'..--,,--.--..."--'•---7-'-----,------...-.---..-•"--I t !,.1,E•BTOTITO1
h--i--., ,•••••••-•. ;
; . ; t.. N"••.- ' i NI •-:..::1 V 1 v 1
1 ! 1."!i...CI •••••::•.;1•!7 C":7i,-,,.. r, ,••••_,,. 1 i ; 1 1 ;i...,...: c.x.:-.1,,:..-..F. T 0-60 000
' •• ''" • '• '''' •••-• ' V.,C1:".44 42 12 ._ li,.t... ...41-1 A- l'•• ' •' C. l• "... 'C''...trkvv't:.-,
c. ... ,„..„,„:„:,:v ,,_, „,-,.., ,1.1;,.,,, 44•,•,,y-ry, j C '.",-..,1,,,,ti.:: ,,„.1.-_21;1 , , t,. j.,...v- 1.,. ,,, ;;r c' ,Ir1,7,1% ,, •ir; j...r•
,.!
1 „,/ ,J",-- •L i,42., - 1,7.:•••, •,41).vq.7..-v5.•.:i.P.r, •Li.,0t.1,-,:;•••."•' I•Jv' .11- "4-1.• :0.-•`t ...-;:•:,t,...-4:4.2. "'s j..:(1,'•' ,/,! I, 1.;-.•.,•••••.,„,...:f!. :"",,i ;••••>,, :.,...,.. ,,I. ' 1'.4.-'''.'.C.' ' .. ',J.."4"-%7 1 t-ti•-"V .1i-••••%. 1.4;r1,'1 i- .‘" i- 2)tk.' '''-C.t•new:z vil-,1..;,,,-, ;,;:,V.-••"•:"...,1.,,:,..t.-•..•
.-............. ...........-........i
•TIKZ.-7;:;f.Tf-TTF,.7.1:.i:;:-------------------F:;ETC- Ti:i':'7.Ti: r---
/ •
I
i. (-,011.,..-muc--..1::' 2:127 .1-3-,12 i --,-. •.• tuc c.. ipolts,p- .37::c01-07.; p3--v
r .60 --'0'-C 1038 . Itt..., .,.. ..
ilpry";47'. V 1,,:r-C /5:.r.rZi I...,1, ......s... i 1
i.,..":!:.,,:t _'..,_.., ,....-____,..,......., _.,,... _,..._. ..........,... ...,1,...1.,,,,r,.., ,_ ....„....._,....„_,.... , vc---.: Tativ:tx.Tcs•u it-Turrsz.r.yuc.^.G t.--,..-o• ;, 1
Zranfirt.,..-c7TeLir 1. i7g. ri-.,6Z5EfEii.71a-i"------i
i . , . .',..i.: ei 1..t.t.,•,,t_14,,_ •• •'tevez , , ,.4
. ,.':;:'..,-cr-..,,,,..,,;---------------------"--.-------r7:--r----.----------'---'t
i ,,,,)• 0.• LICR:!'•'....^':;01'-'0. ra.CL7C7R. /1.;t:• ;11;•;v••• - e 3,r-'53(1-22 a2 , -- 'es-T-531-2. 50
,,........-...1.1.:,..'...,..,,,...... ..,.....---..,-...-... .,..-i
- ,.,...,,..r.—......,....---............--- .
r,•,..- t; ‘,!-., •-pveT pca.rocoxe
1------:-7.7):-.i.z-1---„;-;_,7,5:7:1777°6-77;;,-7,7,--‘,7.7c4-7,31,7zi-i,:r.,....---.........,.....,...,..............................,...,-if.-4.r......4.3...-.....,,.... .attt•,4••••=a-v--tee.r.-=t,to.-7.-g,,,,,,,,...-4.......n.-eac
. Is,..mts•••rae-,-kw.w..........-e-,.....•....,J
1
.• (lit (...r-41.Z, •...;--: I..4),T4';;,(),.:. Cro•!.1,i% LI-:-.111.,.,. C.r.i,:4 J L,0;4.;!•:41.i rl.144 !fen O. `:/: On1ItIr11..4trjr Ir,er V.:-:•Cil OR)I:-•'..• •:t.4.411.:-RIV/1: .,72.t:-., MI'-"n•?.1V.:: 14;iii.,..3 1-*fp:,
iL '!.41.:CEN!'`Ii:11. 1;•It!c• c'ott' ci".1.0 i,f•liti,;4. tv`3,/ •:1)`.;g1!:,,AVF i.',R.elliETY P.1,.. bf:',!:-.' 41-C) Li'zis Po riii,,,,,?Cir it 2riRtic.X.3.11i.i0i4 it. N,t.'i;i1-_,C' raiiii^t: to
; ir.“:11trRE.V?:..i.LfAr.
01 oit.•;:”...)r•Ci-j.:. Vi-n if.-1 CE.CSA:th,i...
i
flij-n.V. 1.1.-4T LEV..t:1•1:.%1 .F-: DE WO ro-svi-ct: 1Xe0',, vol. co1'?z‘.w,c1.,,z t. call_114.-.4‘...:21 PELgr.,M,1 ii-it: 4':•!'-!:1',44:1 fl•'.'fiti:".!-:qt,r ki.•',1;-;•"•Sv''"F.:C• j
C:t 1`.3.1:•IcC.•:.. rE;.- 03 L V1eti.f.1"irri (.)1' iCCV.V.INkr I.- '7,4E140' ER:1.21,13 016 '•:•"r 1 els .L4IE 41:0AFi5tr.:,,,F, 1.1..;,,.:Usr:i;:p is.,.. ....14.. r-,,t Irpz,i!'-:-;
‘.1E._•.,.2i zICV.g, :,1 f•--,:telac, --";..) ,...,1_,..i.i-4 ot.... 124,...01.ft4rii.i0g 0-..t.& Vi-10 C07:7,ecs: 116 441f...4'.2 ClbC0'...1 La::: CF111,:IC:VIL ry,)7,c.,E1I. .1!-•;1?, .,..1
'''':•7SZ.;$4:7egY•1‘ rtl'14/ i gL iCV ar' OE rsv rte,1--ni L i 1,v:1.r)r;.,.f v 1,A e,v--
.:,.., - '.....t....N.,,.,.6. 4A : ert,iv... '.4r,...”. $ CP i ka. i',!, 44 li 6'1.4, . i'.4-....4 Fe...,,,,,,.._;
L'.':!•1.,1.":.'A ti 1 ' f
*•••-‘,........ayt ...........-.*-..................•••......,......••
• • ,
•
STATE OF NEW YORK
WORKERS'COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
la. Legal Name and Address of Insured(Use street address only) lb.Business Telephone Number of Insured
631 439-9860
CDL UNDERGROUND SPECIALISTS INC.
lc.NYS Unemployment Insurance Employer Registration
129A Old Northport Road Number of Insured
Kings Park,NY 11754
1 d.Federal Employer Identification Number of Insured or
Social Security Number
01-0604272
•
2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Being Listed as the Certificate Holder) First Rehabilitation Life Insurance Company of America
Town of Southold 3b. Policy Number of entity listed in box"I a":
P.O.Box 1179 D184558
Southold,NY 11971
3c. Policy effective period:
7118/2015-7/17/2016
4.Policy covers:
a.X All of the employer's employees eligible under the New York Disability Benefits Law
b ❑ Only the following class or classes of the employer's employees:
Under penalty of perjury,I certify that I 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_01/11/16 By
(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number 631 234-5595 Title:Secretary/Treasurer
IMPORTANT If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that
carrier,this certificate is COMPLETE. Mail it directly to the certificate holder.
If box"4b"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed
for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,20 Park Street,Albany,New York 12207.
PART 2. To be completed by NYS Workers' Compensation Board(Only if box"4b"of Part 1 has been checked)
State Of New York
Workers' Compensation Board
According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS
Disability Benefits Law with respect to all of his/her employees.
Date Signed By
(Signature of NYS Workers'Compensation Board Employee)
Telephone Number Title
Please Note:Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of
those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form.
DB-120.1 (5-06)
STATE OF NEW YORK
WORKERS'COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a. Legal Name and address of Insured(Use street address only) 1 b.Business Telephone Number of Insured
631-439-9860
CDL UNDERGROUND SPECIALISTS INC.
129A Old Northport Road lc.NYS Unemployment Insurance Employer Registration
Kings Park,NY 11754 Number of Insured
Work Location of Insured(Only required if coverage is specifically
limited to certain locations in New York State,i.e.a Wrap-Up Policy) I d.Federal Employer Identification Number of Insured or
Social Security Number
010604272
2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Being Listed as the Certificate Holder) Nat'l Liability&Fire Insurance Co.
Town of Southold 3b. Policy Number of entity listed in box"I a":
P.O.Box 1179
Southold,NY 11971 V9WC656949
3c. Policy effective period: i{
08/26/2015 to 08/26/2016
3d. The Proprietor,Partners or Executive Officers are:
X included. (Only check box if all partners/officers included)
❑ all excluded or certain partners/officers excluded.
3e. Demolition is: (Definition of Demolition on Reverse)
❑ included.
0 excluded.
This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "I a" for workers'
compensation under the New York State Workers'Compensation Law.(To use this,:form,New York-(NY)must be listed under
Item 3A.on the.INFORMATION PAGE:of the workers'compensation'insurance policy): The Insurance Carrier or its
licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The Insurance Carrier will also not the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums
or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the
coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for a maximum of
one year after this form is approved by the insurance carrier or its licensed agent.
Please Note:Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,
license or contract Issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers'
Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York
State Workers'Compensation Law.
Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depicted on this form.
Approved by: Michael Bonocore
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: 7-.4"&o.g. 01/11/2016
(Signature) (Date)
Title: Treasurer
Telephone Number of authorized representative or licensed agent-of insurance carrier: (631)234-5595
Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT
authorized to issue it.
C-105.2(12-03)
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 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,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 (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).
sly
* * * RECEIPT * * *
Date: 02/02/16 Receipt#: 199575
•
Quantity Transactions Reference Subtotal
1 Excavation Permits- 1103 $226 50
Total Paid: $226 50
Notes:
Payment Type Amount Paid By
CK#8658 $226 50 C D L, Utilities
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: C D L, Utilities
Po Box 1098
Commack, NY 11725
Clerk ID: BONNIED Internal ID 1103