HomeMy WebLinkAbout19 Middleton RdPermit No. 3
File No./ -3 C
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O. T101715266
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 authorized inspectors to make necessary inspections of the
job site.
Print or Type
1) KEYSPAN GAS EAST CORPORATION d/b/a NATIONAL GRID — GAS CONSTR. DEPT. — 175 E. OLD
COUNTRY RD. — HICKSVILLE, NV 11801
Name of Applicant Address
2) 19 Middleton Rd. Greenport Premises Address
3)
4) Open a- 4'x4' bellhole on the E/s of the road, approx. 43' N/o Wilmarth Ave., to install a
gas service.
5)
6)
7) tidal wetlands' *Yes No _X
*If yes, other Town permits may be required.
Builder's License No. N/A Plumber's License No. N/A
Electrician's License No. N/A Other Trade's License No. N/A
k"
Signature of Applicant
Date; 04/09/15
5) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description 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) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Block , Lot
Completion Date:
Phase
Excavation.........................................................................
FacilityInstallation................................................................
Backfill& Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
ll) Remarks:
12) Insurance Coverage (Attach Copy)
Completion Date
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a) Surety Bond
of $
b) Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
A I . _1 /Service Connections excavations @ $20.00
A2. /Additional Excavations same service @ $10.00 =
No.
B. Excavations I8" in depth or less:
0-100 Lf. = $10.00 -
I.f. @ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lf. _
Additional If (66� .30 =
D. Excavations 5' in depth and over:
0-100 Lf. _ $50.00
I.f. @ $0.50 = $
Additional
E.
Utility Repair Excavations @ $10.00 = $
Repairs same service (a,) $5.00 = $
$150.00
$20.00
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
Y 11611 ILI K4117.`11=1[Fill
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTEN9E OF HIG AY
TOWN OF S(J,U L YO
Vincent M. Orlando
Ll- I�)-/ 5 -
Date
Received by the Town Clerk
Date
Permit Issued
Permit No.
Note: Pennit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pennit must be available for inspection.
D-39
Copy Distribution:
Page 2 of 3
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
I st
2nd
3rd
4m
Findings (use code) Applicant Notified
REMARKS
CODE
(To Permit Clerk)
113— 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
DATE:
LOCATION:
T OWN:
WORK ORDER:
SURFACE:
Macadam Ro d of
Lu
z
Lu
M
PERNUT APPLICATION SKETCH
Village Of
479/2015
19 MIDDLETON RD CROSS STREET I: WILMARTH AVE
OREENPORT CROSS STREET 2: BENNET RD
T101715266
MIDDLETON RD
4:3' 3'
4'x 4 Bell Hole
W
Ch
J
0
N
0
0
0
(;ENER,kL CONDfTIONS OF PER:MI"T
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Permittee's Contractors to Comply with Permit Requirements: Che Permittee is responsible Fur
nforming 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 I lighvvay
Superintendent while acting as the permittee's agent with respect to the permitted activities, and such
persons shall he required to comply with all permit requirements.
No Rip -ht to 'Trespass or Interfere with Private Property Rip_hts: 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 Hip-hway 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, till, 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'rown 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
;hall, 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 till and restore the kite to its
Ionner condition.
Notice of Commencement: At least 24 hours prior to commencement of the project, the permittee andlor
contractor shall notify the rown 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
,hall provide photographs of the completed work to the Covvn Highway Department and request a I incl
inspection.
6. Storaue of Equipment '& Materials: Che 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
,,btained in a manner that does not interfere with normal highway traffic.
l'tility Mark -Cuts: The Applicant' Contractor hall be re,punsible Icr verification ol'all vmstun, utility
mark -outs and shall take all precautions to protect same. Damage to existing utilities shall he the
responsibility of the contractor and shall be repaired at the contractor's expense.
Road Closures: All scheduled road closures must first receive written permission from the Southold Cuwn
Board prior to closing a road, l-emporary lane closures may be permitted with the approval of the Ilighwav
Superintendent. Chis item will included but not be limited to the installation of apprupriate and
Ilag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen
.mergencies require immediate notification of the Highway Department and shall be limited to immediate
and/or expedited restoration of the Work Zone.
'->. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job
to on a daily basis. ,all stockpiled soil as well as all other project materials that will he staged within the
Right -of Way must be delineated with reflective signage or other means to meet the mininnun requirements
„I the NYS DOT Construction Standards.
c;ENER,kL CONDCI'IONS OF PERMIT
.,r
APPLIC.ITION/PERN11T FOR HIGHWAY EXCAVATION AND REPAIR
(Continued)
!0. Install, :Maintain Frosion Controls: Required Erosion Control Measures (i.e. silt fencing) is to he placed
,)n (he downslope cdge 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 �cgctative
,,oyer is established.
I I . Clean Fill Only: All project back -till shall consist of clean sand, gravel or soil (NOT asphalt, ,lag, tlyash,
broken concrete or demolition debris). All unsuitable soils excavated at the site (i.e. Clay, Bog. ctc.) nre to
be removed from the site and not used to backfill any excavation within a 1'own I lighway.
12. :111 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. It'
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 till 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 (1?") 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 specitic 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
art' Southold Town Highway Specifications. ,\II pre-existing road shoulder improvements that have been
di,turbed during construction must be replaced or repaired by the contractor to the satisfaction of the
Ilighway Superintendent.
15. Schematic Plans with All Technical information and Scope of Work: fo reasonably and ,adequately
describe the proposed work, accurate schematic site plans must be provided to show orindicate 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 w kith
A trenching must be indicated by dimension or labeling. Phis schematic site plan must provide details on
.111 restoration required to meet the requirements of these General Conditions and requirements found in the
Southold Town I lighway Specifications.
16, Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner:
A hen Concrete Pa%ements arc Present. Please review Re,lorauon requirements with the I huhway �upenntcndcntl
a) Complete all back -till & soil compaction work as needed to provide a suitable sub -base:
h) Over -cut existing asphalt bell hole or trench by twelve ( I:") inches on all sides.
) Install a compacted lift of -1" thick Stone Blend base ( RCA Blend must meet NYS DOT Specification J:
d) Install a two and one half (2.5") inch compacted lift ofAsphalt Base Course.
) Install a one and one half ( 1.5") inch of Asphalt ( ['Npe 6) Wearing Course. ( Pro% ide AC at all Joints)
\11 work listed herein must meet the minimum requirements of the Southold 1-0\k 11 Highway
�pecitications.
17. Trenching of Pavement Surfaces Exceeding One Hundred (100') Feet in Length: All trenching of
parcment ,urtaces 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 otthe Highway
Superintendent, the entire road section and/or width of road over the entire length of wench ,hall be
repaved with a two (?") inch lift of :\,phalt (Type 6) We:irint; Course ( f�pical, shoulder to shoulder).
Date: 04/16/15
Quantity
1
Notes:
Payment Type
CK #30982
Transactions
Excavation Permits
* * * RECEIPT***
Amount
$170.00
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: National, Grid - Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Receipt#: 183111
Reference Subtotal
1030 $170.00
Total Paid: $170.00
Paid By
National, Grid - Gas Constr.
Dept
Clerk ID: CAROLH Internal ID: 1030