HomeMy WebLinkAboutWickham Ave (2)2) Wickham Ave. Mattituck Premises. Address
3)
4) Open a 41x4' bellhole on the W/s-of the road & open a- 4'x6' bellhole on the W/S of the
road in the grass area, S/o County Road 48, to replace.a leaking gas main.
5)
6) r
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 'cense No. N/A
Q
Signature of Applicant
Date; 06/08/15
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 , Block ; Lot
7) Starting Date:. Completion Date:
8) Work Schedule:
Phase Completion Date
Excavation.........................................................................
Facility Installation...............................................................
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)
9.yFiVLY�
Permit No. TOWN OF SOUTHOLD
l / �1, HIGHWAY DEPARTMENT
rl
File No. I U T ✓ Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
W.O.T101731438
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
applicablelaws, 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) Wickham Ave. Mattituck Premises. Address
3)
4) Open a 41x4' bellhole on the W/s-of the road & open a- 4'x6' bellhole on the W/S of the
road in the grass area, S/o County Road 48, to replace.a leaking gas main.
5)
6) r
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 'cense No. N/A
Q
Signature of Applicant
Date; 06/08/15
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 , Block ; Lot
7) Starting Date:. Completion Date:
8) Work Schedule:
Phase Completion Date
Excavation.........................................................................
Facility Installation...............................................................
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)
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) Securi :
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
Al. _1 /Service Connections excavations @ $20.00 =
A2. /Additional Excavations same service @ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 Lf = $10.00 -
l.f. @ $0.10 =
Additional
C. Excavations 18" in depth to 5' in depth:
0-1001.f. _
Additional If. @ .30 =
D. Excavations 5' in depth and over:
0-1001.f. _ $50.00
I.f. @ $0.50 = $
Additional
E.
No.
Hamnonai
Utility Repair Excavations @ $10.00 = $
Repairs same service @ $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. Ito,
0
TOTAL COST = QO
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway ExcavatioryPermit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
TOWN OF S(
Vincent M. Orlando
Date /
Received by the Town � Clerk d
/ -
Permit Issued �o Dat Permit No. �fl
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
Inspection Date
1st.
2nd
3rd
4 t
D-39
Findings (use code)
REMARKS
Applicant Notified
(To Permit Clerk)
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 to Repair
Page 3 of 3
05/06/2015 03:12 (UTC/GMT) National Grid page 2
AA- i 0AAL 6XID
REQUEST FOR STREET OPENING PERMIT
NASSAU SUFFOLK(
1C-6111.4 ❑ STATE ❑ COUNTY ❑ COUNTY
PEIT
NIS JOB 0 �. LC
DATE
/
NO
r�
—
LOCATION
REASON FOR
OPENING
p
! A L -E—
W.O./PA
FOREMAN
DATE OF
N0,
OPENING
REQUESTED
BY
S, j!y'f
DEPARTMENT
GAS CONSTR. MAINT. & SERVICESf}S"'�j,,R%�
DIVISION
DATE
APPROVED
SKETCH
f1 ftih LAI
.S7
a
9
CENE[L\L CONDITIONS OF PEit:NIIT
;\PPLICATIONMERNUT FOR t(ICHWAY EXCAVATION i\ND REPAIR
I . Permittee's Contractors.to Comply with Permit Requirements: The Permittee is responsible for
ml'orming 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, anil :tiueh
persons shall be required to comply with all permit requirements,
. No Itip-ht to'Trespass or Interfere with Private Property Riuhts: This permit does not convey to the
permittee any right to trespass upon the lands of adjacent property owners in order to perforin 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 parry to the permit.
3. Protection of the Highway and Future Eliuhway Maintenance: if future operations or highway
maintenance projects by the'rown 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.
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 Stuperintendent
may require, remove all or any portion of the uncompleted utility, structure or till and restore the site to its
former condition.
Notice of Commencement: M least 24 hours prior to commencement of the project, the permittee ;uld!or
contractor shall notify the Town Highway Department in writing that they are fully aware of and
undeestand all terms and project conditions of this permit. Upon completion of the work, the contractor
,hall provide photographs of the completed work to the "fawn Highway Department and request a Final
inspection.
6. Storaue of Equinment & Materials: fhe storage of construction equipment and/or materials shall be
cuntined 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.
l'tility Mark -Outs: The .Applic^.nt / Contractor ,hail be responsible to \,eritication of all cxistin; utility
mark -outs and shall take all precautions to protect same. Damage to existing utilities shall he tive
responsibility of the contractor and shall be repaired at the contractor's expense.
3. Road Closures: MI scheduled road closures'must first receive written permission from the Southold Vow n
Board prior to closing a road. Temporary lane closures may be permitted with the approval kif the I lighway
Superintendent. This item will included but not be limited to the installation of appropriate signage 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 lone.
9. NO Construction Debris in Road Shoulder :area: :\II Construction Debris shall be removed from the job
iie on a daily basis. All stockpiled soil as well as all other project materials that v�ill be staged within the
Right -cit Wary must be delineated with reflective signage or other aleans to meet the minimum requirements
ol'the NYS DOT Construction .Standards.
GENERAL CONDI"TIONS OF PIERNU'r
APPLIC.XTION/PERtN1IT FOR HIGHWAY EXCAVATION AND IIEPAIR
�. (Continued)
IU. Install, itilainhtin Erosion Controls: Required Erosion Control Measures (i.c. silt fencing) is to be I?laced
on (lie downslope cdge of any disturbed area. This sediment barrier is to be put in place betore 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 -till shall consist of clean sand, gravel or soil (NOT asphalt, slag, tlyash,
broken concrete or demolition debris). All unsuitable soils excavated at the site (i.e. Clay, 13q, 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 till or soils which exhibit a
well-defined moisture density relationship as determined to be in accordance with AS'rMD 698. Fill shall
be placed in maximum lifts of twelve (12") 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.
13, Restoration of the Road Shoulder Area: All man-made improvements located within existing road
,houlder 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. Ml pre-existing road shoulder improvements that have been
,listurbed during construction must be replaced or repaired by the contractor to the ,atistaction of the
Ilighway Superintendent.
15. Schematic Plans with all Technical information and Scope of Work: ro reasonably and adequately
Ascribe 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 sire of bell holes or w idth
ofirenching must be indicated by dimension or labeling. this 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 Highway Specifications.
16. Pavement Reconstruction: ;VI Pavement sections must be reconstntcted in the following manner:
Mme: when Concrcte Pavements are Present. Please roiew Re,torauun requirements wth the I lightvay Supchilmi lent)
:1) Complete all back -till & soil compaction work as needed to provide a suitable sub -base:
h) (Iver -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):
J) 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 (-rrpe 6) Wearing Course. ( Provide AC at all joints)
All work listed herein must meet the minimum requirements of the Southold Town I lighway
Specifications.
17. Trenching of Pavement Surfaces Exceeding One Hundred (100') Feet in Length: All Irenchine of
pavement -,urfaces 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
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 ('rvpical, shoulder to shoulder).