HomeMy WebLinkAbout8530 Peconic Bay Blvd * * * RECEIPT * * *
Date: 03/23/16 Receipt#: 201773
Quantity Transactions Reference Subtotal
1 Excavation Permits 1118 $170 00
Total Paid: $170 00
Notes:
Payment Type Amount Paid By
CK#34376 $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
Bld 3 Fl 1
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID 1118
Permit No. , RECEIVEDTOWN OF SOUTHOLD FFa
HIGHWAY DEPARTMENT g• �' Cz
Peconic Lane MAR 2 1 2016
Peconic,New York 11958Ata. ca.
(631)765-3140 Southold TownClerk ��i
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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,SuffolkCourity,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.
Print or Tye Keyspan Gas East Corp D/B/A- National Grid
Gas Permits Dept. Bldg: 3 FI: 1
175 E. Old Country Rd Hicksville, NY'11801
Name of Applicant Phone Number Address of Applicant
2.
Name of Contractor Phone Number Address of Contractor
tet 9t7
3.
Namerof Pr erty Owner Requesting Service(if ap licable) Address,of Owner
4. la-gio raw I14 ( ,� - i 30 `.�/o Tri imei /yr
P (Street Description and Location Number,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 Signaa of plicant
k
Application./Permit Form is 3i' t(�
/
Required for a complete application! ((((
Date
5., '(a)'Attached plot plan ta 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 pavementrestoration 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 , Block , Lot
7. Starting Date: q )r( (�4 Completion Date: q/1J r 1(
8. Work Schedule: Phase Com!Action Ilnte
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 Utility being modified.
10. Estimated Cost of Proposed Work: $
11. Remarks: IP Poi ( ) Uit- eL- -67 Ito :M-62--
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D-39 1 of 3
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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:
Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and$'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 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.
1-70
Al. l /Service Connections excavations @$20,00 $ PD'
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 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 N
TOTAL$ /D- ?-°
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:
i accordance with
this application and subject to,the"General Conditions"and"Special Conditions"•of permit(if a )attached heretv
SUPERINTEND.- T t HI rs YS/
TOWN OF SO; HJ ��� J` *R
Vi'cen M.Or ando
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Date
Date-Received by the Town Clerk 3 t l
Date Permit Issued 3 3 I I (o Permit No. '1 IA 8
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.
D-39 2 of 3
Copy Distribution: 113 Q�
Permit-# uJ
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant-Notified
1"
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 InspectorHolding for Final Settlement of Excavation
RFR Ready for Repair
D-39 3 of 3
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cd PEC APPLICATION SKETCH M
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Village Of
DATE: 3/15/2016
LOCATION: 8530 PEC BAY BLVDcioss STREET 1: A J MASTERS RD A
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,TOWN: LAUREL crOss STREET 2: BRAY AVE U(,
c.
WORK ORDER: T101823917
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,SURFACE:
MacadamRo.d.E House NO.
(i) 8530 < ii
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4' x 4' Bell Hole °
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' GENERAL-CONDITIONS OF PERMIT - '
APPLICATION/PERMIT,FOR HIGHWAY EXCAVATION AND REPAIR,
1. P,ermittce's4Contractors to ComnIfWith`+FerminRedtiirementsi, TheTermittee is responsiblefor ,
'informing its-independent contractors;;employees„agents and assigns of their responsibility, comply with
• this,permit,'including all specialIsite specific.and'general:conditions'imposed by the Highway
' Superintendent whileacti`ng as.thepermittee's agentwith respectto the permitted activities,and such
persons shall be,requited to comply with all permit requirements.
2. N&Ri'klit'to.Tresnass or''•Inter'ferewith�Private Pre perti%'Rii hts:;This permit does.not convey to'ththe
permittee any,right to trespass upon the lands of adjacent.property,owners in order to,perform'the permitted '
work nor does itauthorize the impairment of any rights;title orinterestin real'or,personal'property held-or ',
' vested in,a,personnota party to'the permit:
3. Protection:oftiiellighwav and Future-IIighway`Maintenance:,,If future operations or highway
maintenance,projects'by-the TownofSouthold=require••analterationJin=the position.ofthe,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 vehicularor 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 Superintendent finds that the,issuance of the
permit,was'illegal'or unauthorized-or thatthe;`applicantfailed to comply with any ofthe.terms and ,
conditions-of the,permit or Chapter 237 of the Town Code.
4. Revot`
cation`of the,Permiby,tlieHighwav Superintendent: --If_the Highway Superintendent deems it
' necessaryto revoke this permitand„the projecthereby,authorized has not,been',completed,the applicant,,
shall,without expense to the Town,and to such extent and-in such time Elnd'mànner as the Superintendent
mayrequire,remove,all or any,portion;of the uncompletedutility;structure or fill and restorethe site to,its
former condition.
5. Notice oCommence
fment:- At least24 hours-prior-to commencement Of the project,'the permittee and/or
contractor shall:notify the,Town Highway Department in writing thatthey',are.fully aware of and
understand,all terms and;projectconditions'of this permit Upon.completion of the'work,the-contractor
shall,providephotographs of the-completed work,to.theTown Highway Department and:request a Final
inspection.
'6. ,Sto'ratte oflEquipnient&'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. Utilitv:Mark-Outs:' The-Applicant/-Contractor shall,beresponsible,for verification of all existing-utility
mark-outs and shall-take all precautions-to protectsame. Damage to existing utilities,shall be the
responsibility of the-contractor and,shall'be repaired atthe,contractor's expense.
8. 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 notbeliniited to th 'installation of appropriate signage and
flag men to,stop and start,traffic to-allow for single lane traffic. Road Closures due to unforeseen
emergencies requireimmediate'notificatibn;of the',Highway Department and'shall be limited to'immediate
and/or expedited restoration of the-Work Zone,
9. `No•Construction•Debrisin Road-Shoulder Area: All Construction Debrisshall be removed-from the job
site on a daily basis. All stockpiled soil as well asall 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-Erosiom:Coatrols:.,Required Erosion Control Measures(i.e.-silt fencing)isto'be placed,
on the‘downslope,edge-of any'disturbed area. This•sedimentbarrieris 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 dean sand,-gravel or soil(NOT asphalt,'slag,flyash ,
broken,concrete or'demolition 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,anyexcavation within a,Town Highway. -
12. -Ali Areas'of Soil Disturbance: All areas of soil disturbanceresulting from the approved projectshall be
stabilized,to the,satisfaction of the Highway,Superinterident immediately following project completion. •If
'the',project'site remains'inactive;for more than_48,hours or;planting"is,impractical due to,the',season,,th'en. ,
the area shall be stabilized with straw,hay_mulch and/or jute matting until weather conditions favor
:germination.
1-3.'Backlit 8i-Compaction of'nll 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%0)percent maximuni dry,density: 'Suitable hydraulic compaction:bywater jetting at three-foot
intervals will-also be permitted subject to,'a project specific approval by the HighwaySuperintendent.
-14.',Restoration ofthc�,Road Slioulder'-Area: All man-made improvements located'within existing road
sho'u'lder,areas must beprotected to'the'greatest extent practical. 'Items,would include butnot be limited to
driveway&private'road aprons,mail-boxes,sprinkler systems,trees and ornamental plantings.
Excavations through driveways'and private-read pavements must be"reconstructed to•meet all requirements
of Southold Town'Highway Specifications; 'All pre=existing road shoulder-improvements that have been
disturbed d'uring,construction must be replaced or repaired,by the contractor'to the:satisfaction of the , , '
Highway-Superintendent.
15.•,SclremntieTlaN s with,a1FTechnicalinformation and'Scone•'of Work:: To reasonably and adequately
'describe'the proposed work,-accurate-schematic site plans,must be'provided to shower indicate all
.proposed construction activity required under this permit. Al1'Pavement'surfa'cesscheduledfor excavation
must be saw cut to,the-full,depth of:asphalt and/or concretepavements. ;Accurate°size+'of bell holes or width
of trenching must be,indicated by dimension orlabeling. 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,asphaltbellhole'or trench'•by twelve•(12")inches on all sides;
c) Install,a'conipacted lift'of 4"thick Stone Blend base'(RCA Blend must meet NYS'DOT Specification);
d)Install a two sand'one half(2.5")inch'compacted lift of Asphalt Base Course;
e) Install a one and•one_half(1.5")inch-`ofAsphalt_(Type'6)'Wearing Course.,'(Provide'AC at all joints)
All work listed-herein mustmeet the minimum requirements of the Southold Town Highway '
Specifications. ,
17.`Trenchintr-of Pavement:Surfaces-Exceeding Oue'Hnndred'(100')Tcet-.inLength:;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 satisfactioni of the,Highway
Superintendent,the entire road section and/or width'ef'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).
SI pi