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Pr -mit No�
www of SOUTHOLD
HIGHWAY DE'PARTMFNT
peconic Lane
,peconic, New York 11958
(631)765-3140
APPLLCA ION I palkMIT FO IiIGti -"
ii hways of the Town of Southold for r na tlicable flaws. o dinances or 118=0 Of an Excavation ermit
New York, and other pp
APPL.ICAT'l 1S 1i);1l;EaY made to the Superintendent of g with all applicable laws, ordinances, codes and
make
in described. Thc applicant agrees to comply if any and to permit authorized inspectors
.pursuant to Chapter, 23? of the Cadc of the Town of Southold,
5u1'folk COMLY,
regulations for the excavation here
uluiions, the attached General Conditions of permit" and "Spacial Conditions ,
red
necessary inspections of tile, job alta.
Pr! 8
Name
Name of Contractor
Address of Owner'
3. Owner p�gtiesting Service (if applicable) x
Name of Prop Y LW)
4 b Hamlet, Cross Street) No
a, Yes
Work Description an Location (Street Num �� feet of tidal wadat►ds?
(a) Ie construction located within 7S r ,Tired.
+Lf yes, dii,,sr Town permits may b0 D4 -
Signalure of Applicant
NOTE: All information, requested by this
Application /permit Form W 0 0
Required for a complete application! Date
osed work. Provida 110040 sehematic site Plan showing rho
legat iltp adJoln09101116areas, and give a detailed descriptio+i of
g (a) Attached plot plan to reasonably and adequately dea Promises' public streets or
scribe the prop
location of all proposed excavations and roi
all site and pavement restoration rwnorl And licenset. s fot this project.
(b) Attach all other nor-essary p w E><cavt+tlon Kermit by the TOM ClO k,
(c) Work covered by this appilcation may not commence before issuance ar a Nigh a�' Section _ Lot
6. Tax MAP No.: District 101)0. (p - 2.3- Is-,
Completion Date,
z. Starting Date:
3 l
�'omolotion n to Work Sebe ,1
8. Work Schedule: Excavation Must be provided
Facility Installation for consideration as a
Backfill & Completion Complete Application.
pavement Replacement
c. �vlsr�
9. Under which authority is appiieation being made: m authority iTottt, the Utility being modified.
See Town Code Chapter 237 (E) - Provide Resolution by, tY
10. Esti mated Cost of proposed Work:•
11. Re marks
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12, Ms urance Courage: (Attach Copy)
(a) Insuyvnce Company:
(b) Policy;
(c) Statu whether policy of certification on rile with the Highway DoPattment:
(d) Coverage required extended to the Town:
Any Loss including Bodily injury, property or commercial injury caused by or nttributeble to the work perform
$1,000,000 per Occurrence and $ 2,000,000 general aggregate.
13. Securit y: or Certified Check provided in the total Amount of ffi
(a) Surety Bond
2 years or 3 years.
(b) Maintenance 13ond,provided:
14..Fees for Applications and permits:
50.00
Basic Application Fee $ 00_
A1. _/Service Connections excavations X0.00
No. $10.00 $
A2. / Additional t3xcavations same service @
No.
B. Excavations ? r
I r, in depth or less $ S �
0.100 L.F. =$10.00; Additional / ]S� L•F 50.10
C. excavations Ir, in dopth to 5' in depth L F $0.30 $
0-100 L.F.= 530,00; Additional �..�
D. Yixcovations, 5' in depth and over L.F. $0.50 $
0.100 L.F..= $50.00; Additional @
E. Utility Repair Excavations @ $10.00
No.5
_ Repairs same service @ $5,00
•�Additional
TOTALS—=
Notice to public utilities proof must be provided and
F Shall be attached to this application prior to issuance of permit. «
*tion granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
Authorize is hereby
this
To the "General
and
in accordance wrttr
ions" of permit (if any) attached hereto.
Date Received by the Town Clerk Lj l ) 5
Date permit issued
�5 Permit No.
NO'T'E: permit expires one (i) year from data of issuance.
No work to startwlthout24 hour notice to Superintendent of Highways.
Por•m it must be available at all times for inspection, on siW; during construction.
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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.
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.
4
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 ordemolition 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, hav 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 (IS') 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).
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