HomeMy WebLinkAbout500 East RoadPermit No. /n 3
File No. lo3 Q—
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.T101717600
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, NY 11801
Name of Applicant Address
2) 500 East Rd. Cutchogue Premises Address
3)
4) Open a- 4'x4' bellhole on the S/s of the road, approx. 340' E/o Pequash 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
Signature of Applicant
Date; 04/16/15
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 Ila ,Block , Lot ( U Q
• 3
7) Starting Date:
8) Work Schedule:
Completion Date:
Phase
Excavation........................................................................
FacilityInstallation...............................................................
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) 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 1. _1/Service Connections excavations @ $20.00 =
A2. /Additional Excavations same service @ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 Lt: _ $10.00 -
I.f. @ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lf =
Additional If @ .30 =
D. Excavations 5' in depth and over:
0-100 Lf = $50.00
Lf. (il $0.50 = $
Additional
E. Utility Repair Excavations @ $10.00 = $
No.
Repairs same service c, $5.00 = $
Additional
$150.00
$20.00
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = $170.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTEN
NT OF HI WAY
TOWN OF S
L YO K
incept .Orlando
j
Date
Received by the Town Clerk / oZ
Date
Permit Issued � /5 Permit No.
/ 0
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
Copy Distribution:
Page 2 of 3
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
I St
2nd
3rd
4 t
Inspection Date Findings (use code) Applicant Notified
(To Permit Clerk)
REMARKS
CODE
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 :
L OCATI CN:
T OWN:
WGRK ORDER:
SURFACE:
Macadam Ra d (f)
cry
r—
w
M
4/161'015
500 EAST RD
CUTCHOGUE
T101717600
PERMIT APPLICATION SKETCH
Village Of
CROSS STREET 1: PEOUASH AVE
CROSS STREET 2: BETTS ST
EAST RD
340'
4' x 4' Bell Hole
M,
GENERAL CONDITIONS OF PERMIT
;APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
I . Permittee's Contractors to Comply with Permit Requirements:_ The Permittee is responsible fur
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 I lighvvay
tinperintendent 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 Ri::hts: Chis 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 Hi6way 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 rinds that the issuance of the
permit was illegal or unauthorized or that the applicant tailed to comply with any of the terms and
conditions of the permit or Chapter 237 of the 'Gown Code.
-l. 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
Iormer condition.
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
,hall provide photographs of the completed work to the Tovvn Highway Department and request a Final
inspection.
6. Storage of Equipment & Materials: I'he storage of construction equipment and/or materials shall be
confined within the project work area and/or adjacent areas where permission ' legal ;recess has been
Obtained in a manner that does not interfere with normal highway traffic.
Vtility dark -Outs: The Applicant ' Contractor hall be responsible for verittcation of crll vmsnn, utility
mark -outs and shall take all precautions to protect same. Damage to existing utilities ,hall he the
responsibility of the contractor and shall be repaired at the contractor's expense.
Y. Road Closures: All scheduled road closures must first receive written permission from the Southold Coven
Board prior to closing a road. I'emporary lane Closures may be permitted with the approval of the Ilii hvvav
Superintendent. phis item will included but not be limited to the installation of appropriate si,nage and
Ilag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen
.mcrgencies require immediate notification of the Highway Department and shall be limited to immediate
rnd/or expedited restoration of the Work Lone.
1), No Construction Debris in Road Shoulder :area: All Construction Debris ,hall 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
01 the NYS DOT Construction Standards.
}` GENERAL CONDrrIONS OF nion'r
- APPLICAMON/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
(Continued)
10 Install, Maintain Erosion Controls: Required L'rosion Control Mea5ureS (i.e. gilt I'encing) is to he placc�l
m the downslope edge of ;tny disturbed arca. this sediment barrier is to be put in place be fore any
disturhance of the ground occurs and is to be maintained in good functional condition until thick �c�ctative
citvcr is established.
11. Clean Fill Only: All pro -jest back -till shall consist of clean sand,,ravel or soil (NOT asphalt, slag, flyash,
broken concrete or demolition debris). Ali unsuitable soils excavated at the site (i.e. Clay, Bog, ctc.) are to
be removed from the site and not used to backfill any excavation within a I'own I lighway.
12. :\ll .-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 18 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 it
well-defined moisture density relationship as determined to be in accordance with ASTMD 698. Fill shall
he placed in maximum lifts of twelve (1?") inches thick and shall be mechanically compacted to a Ninety-
tive (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.
1 1. Restoration of the Road Shoulder :area: All man-made improvements located within existing road
,boulder 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
,li.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. ;SII Pavement surfaces scheduled for excavation
niust be saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of bell holes or width
ol'trenching must be indicated by dimension or labeling. I'his schematic site plan must provide details on
Lill restoration required to meet the requirements of these General Conditions and requirements found in the
Southold Town 11ighway Specifications.
16, Pavement Reconstruction: All Pavement sections must be reconstructed in the tbllowing manner;
\oe 'A hen l on -rete Pavements are Present. Please re�iew Restoration requirements \�ith the I Iiehwa} luper uttcnLletit)
,t) 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 ( 12") inches on all sides;
�) Install a compacted lift of -l" thick Stone Blend base ( RCA Blend must meet NYS DOT Specification );
d) Install a two and one half (2.5") inch compacted lite of Asphalt Base Course;
v) Install a one and one half (1.5") inch of Asphalt (Tv pe 6) Wearing Course. ( Prov ide AC .it all joints)
\11 work listed herein must meet the minimum requirements of the Southold Town Highway
�pecitications.
1',. Trenching of Pavement Surfaces Exceeding One Hundred (11)0') Feet in Length All irenchinc of
pavement surtaces 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 ofthe Highway
�uperintcndent. the entire road section and/or w idth of road over the entire length of trench hall be
iepaved with a two ( -) inch lift of Asphalt (Tope 6) Wearing Course ( fvpical, shoulder to shoulder).