HomeMy WebLinkAbout745 King St06/16/2015 TUM 1s: 52 WAX 0j1f0Zli2v •roWn ox 0vuz.c1v1a nwy --V %W—,
Permit No. V J `I'
TOWN OF SOUTHOLD�'�A'
HIGHWAY DEPARTMENT
Peconic Lane
Z Peconic, New York 11958 %
/0 1 �� (631)765-3140
U�
APPLIC&ITON PERMIT FOR HIGHWAY EXCAVATION A PAIR
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.
Name of Applicant
Phone Number , Address
2. '-
Name of Contractor Phone Number Address of Contractor
3.
Name of Property Owner Requestin Service (if applicable) Address of Owner Al—
fy
4.7qvt- K•V.- .s �s 3 7 / E✓�o /� ' vlS P-0ti� i��
Work Descrip on and Location (StrectNumber, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? .* Yes No
*if yes, other Town permits may be required.
NOTE: All information requested by this Signature of Applicant
Application / Permit Form is —7 67 -
Required
Required for a complete applicationl 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 projoct.
(c) Work covered by this application may not commence before issuance of a Highway Excavation Permit by the Town Clerk.
6. Tax Map No.: District1 Saction Block of
7. Starting
oc `
"N i2 � I C p
om letion Dete: %1i
Data:
8. Work Schedule:
Phase
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
9. Under which authority is application being made:
See Town Code Chapter 237 (E) • Provide Resol
16. Estimated Cost of Proposed Work: $
11. Remarks: _ _ 1� a S SQiJ, Ci
Comoletion Date
or authority from, the Utili 5
3york Schedule
Must be provided
for consideration as a.
y
AC/omLLplete Application,
�lk �a r'
being modified.
(1) W LJ -1564
D-39 1 of 3
06116/2015 TUE 140 5E Fax 091 /0'1 /OV Town o= DouLnpTp nwy uoup
12. Insurance Coverage: (Attach Copy)
(a) Insurance Company:
(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 orcommercial injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and S 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 oxeavation 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 C $20.00 $ 2 ,0 0
No.
A2. / Additional Excavations same service ® $10.00
No.
B. Excavations 18" in depth or less
0-100 L.F. = $10,00; Additional- L.F. ® $0.10 $
C. Excavations 18" in depth to 5' in depth
0-100 LF, = $30.00; Additional L.F. Q $0.30 $
D. Excavations 5' in dopth and over
0.100 L.F. = $50.00; Additional L,F. a, $0.50 $
E. Utility Repair Excavations Q $10.00 $
No.
Repairs same service ® $5.00 $
Additional
.TOTAL $_ 1-76 ' 0,1
F., Notice to public utilities proof must be provided and
Shall be attached to this application prior to issuance of permit.-
Authorization
ermit.Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
in accordance with
this application and subject to the "General Conditions" and "Special Conditions" of permit (' i;E
hed h eto.
SUPER iNTE EQ A
TOWN OF YO
M. Orlan
,7
,te
Date Received by the Town Clerk `
I Z77
Date Permit Issued 1� Permit No. I d J
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.
w
D-39 2 of 3
06/16/2015 TUE 14:52 FAX,6j1i65115V TOWN 0= b0utn91C evly w6V er-• •••
Copy Distribution;
Permit #
Highway Department
NEngineer (with page 3)
Applicant
Town Clerk (Original)
IN'SPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
let
2nd
;
3rd
4th
REMARKS'
CODE
ID 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
RPR Ready for Repair
(To Permit Clerk)
D-39 - 3 of 3
Ew!
DATE:
LOCATIM
T OWN:
WORK ORDER:
.SURFACE:
_F
..Macadam Roe d P
n
r')
z
0
n
W
ry
0
D
711512015
745 KING ST
ORIENT
T1017 48921
F.ERAUT APPLICATION SKETCH.
Village Of -
CROSS STREET 1: MAJORS POND PATH
CROSS,STREET 2:' NELSON] ST
KING ST
F-77
357'
41 x. 4' Dell Hole
0
Lu
z
06/LO/Zvi 0 1'Uis tre:7A , rti.% all io�3iI;IV ivwu vl ovuwuv.+.0 aan,y .. e
'W--, .. .
GENERAL CONDITIONS OF PERMIT
APPLICATION/1'ERMIT FOR HIGHWAY EXCAVATION AND YtEPAIR.
1. Permittee's Contractors to Comoly with Permit Requirements: The Permittee is responsible for
informing its independent contractors, employees,'agents and assigns of their responsibility to eomply.with
this perrnit, including all. special/site specific and ,goneral 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 Tresnass or Interfere with Private Properly 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 pennitted
-work nor does it authorize the impairment�of any rights,.titla, or interest, in real or personal,property held or
vested in a person not a party to the permit.
3. Protection of the Highway wind Future,Hlehway 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 maybe revoked if the Highway Super'interident.ftnds'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: I 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 ofthe.project, the perrnittee.and/or
contractor shall. notify, the Town Highway -Department in writing that they are fully aware of and
understand: all terms an&prcject.condition's 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 EC uipment &.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 Marc -puts: 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 .contrac"tor and shall .be repaired at the'coritractor's expense.
8. Road Closures: All scheduled road closures. must firsfreeeive-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 &s,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.rneet the minimum requirements
of the NYS ,DOT Construction Standards.
0b/1®/GV LU 1L UM L.;JU
GENERAL CONDITIONS OF PERMIT,
APPLICATION/PERMIT FOR HIGHWAY FACA'VATIONAND, 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. 'A11 project back -fill shall consist of clean -sand, gravel or soil (NOT asphalt, slag, flyash;
broken concrete or:demolition debris): All unsuitable-soU excavated,at the site (Le. Clay, Bog, etc,) are to
be removed,from the site and,not used to backfill any excavation within a Towti,Highway.
12. All Areae of Soil Disturbanco All areas of soil disturbance resultiiig.from�the approved project shall be
stabilized to the satisfaction of the Highway Superintendent immediately following project completion. If
the project site remains inactive formora than 4$' 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 .
gcrmination. ,
13. Backfill & Comnaction of all Ezeavations: Back Fill shall.consist�of clean fill or soils which exhibit a
well-defined :moisture density relationship as,detetmined to be in accordance with ASTMD 69&, 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
in will. -also be permitted subject to a proJect specific approval by the'Highway Superintendent.
14. Restoration of theRoad Shoulder Area': All. man-inade'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 boxos, sprinkler systems, trees and ornamental plantings.
Excavations through driveways and private road pavements most be rbconswcted 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 Seodeof - orkt To -reasonably -and adequately
describe the proposed work, accurate. schematic site.plans must be provided, to show or indicate all
proposed construction aetivity.required under this pormit, 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
al l restoration required to meet the. requirements oft hese General Conditions and requirements found in the
Southold Town Highway Specifications,
16, Pavement Reconstruction: All pavement sections mus0e reconstructed in the following manner;
(Note: When -Concrete Pavements are Present,.Plcase review Restoration rcquiremeh1s-with'tho 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 D.OT Specifrcation);
d) Install. a two and one half (2.5") inch compacted lift of Asphalt Base Course;
e) Install a one and one half (1.511) 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. Tr uchin of Pavement Surfaces Exceedin One undred 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. Onco'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),