HomeMy WebLinkAbout1805 Jockey Creek Dr r__ , q3FFat�Permit'No. J®8 , _
, TOWN'OF SOUTHOLD
- - HIGH WAY.DEPARTMENT ' r';
n - , PeconicLane', '' ,`
Peconic,New York 11958 sy :. `',:
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(63`1)765-3140 '-ol.. ,
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APPLICATION/PERMIT FOR•HIGHWAY EXCAVATION'AND REPAIR ' .
APPLICATIOIS HEREBY'made to the Superintendent of Highways'of the Town of Southold for.'the(
Nissuance of an Excavation Permit
' pursuant to Chapter•237'ofthe Code ofthe Town'of'Southold,SuffolkCounty,New York,,and other applicable laws,ordinances or•
regulations for each indiVidnaf contiguous excavatibn-project herein deseribed:••The'applicant agrees to comply with•all'applicable laws,
ordinances,codes;and regulations,'the attached"General Conditionsof Permit"and"Special Conditions",if any and to`permit authorized
inspectors to make necessary,inspections of the'job'site. . , ,
Print or Type " -
--,_ . • ' - Keyspan Gas East Corp D/B/A-National Grid • j/b 64,6- 440
- 1. ,Gas-Permits Dept. Bldg: 3 Fl: 1•' : ''' ' •
. Name of Applicant 175 E. Old'CaAni?f9l6ksville, IslC'fplicant
2. , • , .
Name'of Contractor Phone Number Address of Contractor
3.
Name of Property'Owner Requesting Service(if applicable) Address of Owner ,
4. / ���/C 2 .� �V GP - /i� F� ! G��d' ®l9 Ai� �
Work-Description•and Location(Street Number,Hamlet,:Cross Street),
' '(a) Is construction'located within 75 feet of tidal wetlands? *Yes - ' . . ,No
*If yes;other Town permits may be required. /
s , f i. �'
NOTE: All'information requested by this Signature of Ap.licant
' Application/Perinit'Form'.Is, Q '
Required'for complete application! 1// o r'��
- • Date
5. (a) Attached plot plan to•reasonably`and'adequately describe the proposed work. Provide accurate-schematic siteplan 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 project., • -
(c) Work covered by this application may not commence before issuance of a Highway,Excavation Permit by the Town Clerk.
6. Tax Map'No.: District 1000 , Section 70 . , Block p( , Lot 1C ,
' 7. Starting Date: / 0-;/i7'l /5- Completion Date: /a iP/A�
S. Work Schedule: Phase Completion-Date
Excavation;,, ',Work Schedule
Facility Installation Must be provided
Backfill&,Completion for'consideration as'a
Pavement Replacement Complete Application.
9. Under which authority is-application being•made: '
See Town Code,Chapter 237'(E)-Provide Resolution by,or authority from,the Utilitybeing modified.
10. Estimated Cost of Proposed Work: $ - _ _.
11. Remarks:
C' '
' D-39 1 of 3
12. Insurance Coverage:(Attach Copy)
' (a) Insurance Company: '
(b) Policy II:,
(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 or commercial-injury caused by or attributable to the work performed:
$1,000,000 per Occurrence-arid$2,000,000 general aggregate. ,
13. Security:
(a)Surety Bond, - or Certified Check provided in the total Amount of$
(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 excavation within any
50'Radius whether or not they May inter-connected by open trench or-directional boring. 'a
The total nuinber,of Project Locations'shall tie subject to the approval of the Highway Superintendent.
Al. I /Service Connections excavations @$20.00 $ CrgN'' P°
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 ' - 2Z
' 0-100 L.F:_$30.00;'Additional L.F.@$0.30 $
D. Excavations 5'in depth and over ,
0-100 L.F.=$50.00;Additional L.F.@$0.50 $
E. Utility Repair Excavations @$10.00 $
No. -
Repairs-same service @$5.00 $
Additional
TOTALS /70 • 0
F. Notice to public-utilities proof must be provided and .
' Shall be attached to this application prior to-issuance of permit.
* * * * * * * * * * * * * *
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 if any)attached h-reto.
SUPERINT a„-NT 6, .:4 lAy:°
TOWN OF �•; i' • l;,'vi YO l
Vin - .Orlando
/1 -ft
Date
Date Received by the Town Clerk 18-SO-0,
Date Permit Issued Permit No.
NOTE: Permit expires one(1)year from date of issuance.
No work to start without24 hour notice to Superintendent of Highways.
Permit must be available at all times for inspection,on site,during construction.
D-39 2 of 3 3
Copy Distribution:
Permit#
Highway Department
Engineer (with page 3)
Applicant
Town Clerk (Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
REMARKS
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 for Repair
D-39 3 of 3
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
Superintenden(while acting as the permittee's agent-with-respect to the permitted activities,and such
' ,
persons shall berequired to comply with all permit requirements. '
', 2'. No'Righrto 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,orderto 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 requirean alteration inthe position of the utility,structure
or work herein-authorized,.or if,'in'the;'opinion of theHighway-Superintendent the work performed under
this"permit shall cause unreasonable obstruction,to required highway Maintenance-or endanger-the health,
safety and/orwelfare 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 applicantfailed to comply with any of the terms and
, ' conditions of the or Chapter 237'of the'Town Code. ' ,
4. Revocation of the Perinitby"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
mak regUire,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 writingthat 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 hila 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. ,
' 8.- Road Closures: All scheduled road closures must first receive written.permission frotn,the Southold Town
'Board,prior;to,closing a road. Temporary lane closures maybe 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-iinmediate,notification Of the Highway Department-and,shall be limited to immediate
' ' and/or expeditCd-restorati'on'of the Work Zone.
9. -No'Construction.Debris in Road Shoulder Area: All,Construction'Debris shallbe 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. "-
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,hay 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(1.5")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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- PERMIT APPLICATION SKETCH
-Vilia,ge_Of
11
DATE: 11/18/2015 Q
74,
LOCATION: 1805 JOCKEY CREEI,<•: s STREET I: '0 Ai<L AWN AV ›,
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* * * RECEIPT * * *
Date: 12/01/15 Receipt#: 194769
Quantity Transactions Reference Subtotal
1 Excavation Permits 1081 $170.00
Total Paid: $170.00
Notes:
•
Payment Type Amount Paid By
CK#33244 $170.00 National, Grid -Gas Permits.
Dept
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
•
Name: National, Grid -Gas Permits. Dept
175 E Old Country Rd
Ops BId 3 Fl
Hicksville, NY 11801
Clerk ID: CAROLH Internal ID: 1081