HomeMy WebLinkAbout4 Middleton Rd r
* * * RECEIPT * * *
Date: 03/30/16 Receipt#: 202131
Quantity Transactions Reference Subtotal
1 Excavation Permits 1120 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#34466 $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 1120
Permit No. l cg 0
TOWN OF SOUTHOLD, suFZ,-
RECEIVED HIGHWAY DEPARTMENT -` °°a
Peconic Lane %1
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MAR 3 0 2016 Peconic,New York 11958 •c M' '=..�,
(631)765-3140 �4 ., �a°�;
Southold To .•,' : 3., TION/PERMIT FOR HIGHWAY EXCAVATIONAND 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,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.
Pr!ntorType Keyspan Gas East Corp D/B/A National Grid
Gas Permits Depth Bldg: 3 Fl: 1
i 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
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. M1 PNera,) i ) l5 fff'6/a Nara G)/o �o(?a.6 6i
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. /
lam- '
NOTE: All information requested by this Sig ture,ofApplican
Application/Permit Form is ����7 4'
Date Required for-a complete application!
Date
and�, f•
5. (a) Attached plot plan to reasonably and adequatelydescribe the proposed work. Provide accurate schematic site plan showing,tlie
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 , Block , Lot
7. Starting Date: Completion Date:
8. Work Schedule: Phase Completion Dalt
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 ofProposedWork: '/ $ ,�(� d
11. Remarks: Oki) l'! 4 `� `•c( 144144 / .9 L6 �� � /t ,o)k 66;k/et-
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 theHighway,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 Locations would include each`Bell Hole and/or every road opening or excavation within any
50',Radius whether or not they may be inter-connectedby 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 @'$20:00 $ 0, ,
M.
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 S.
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 p�
TOTAL$ l'9a ' fry
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)ttached hereto
SUPERINTENDEN �0,,HIG.. • / 'S
TOWN OF SOU H "O +, . (I K
Vincent M.Orlando
3-- /6
// Date
Date Received by the Town Clerk 3 ao I 1(O
Date Permit Issued 3 l go( 1 C Permit No. I I ao
' 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
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PERMIT APPLICATION SKETCH M
a
Village Of
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DATE: 3/25/2016 "�
LOCATION: 4 NIIDDLETON RD CROSS srREET 1: NORTH RD `)
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T OWN: GREENPORT mass STREET 2:. BENNET ROAD EXT
1V K ORDER: T101826516 ,n
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SURFACE:' o
Macadam Rod Ho eNO. CL '
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4'=x 4' Bell Hole
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MIDDLETON RD
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Copy Distribution:
Permit# Ltd Q
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 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'sCaiitractors'to''Comrmeg
ply'witlfi eittRi�iremen`t's: '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',imposedbythe:Highway
' Superintendent'while acting as the permittee's'agent With respect to'the permitted'activities,and,such
persons,shall be required to comply withperniit all requirements.. ,
2. NC-Riklifto,Trespass or Interfere:with;Pr"ivatelPrOperty Rithts:_This permitdoes 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.iinpairment of any,rights,titlei,or'interestin,real or-personal'propertyhel'd'or
' " 'vested in,a-person nota pary to the permit. . ,
'3. 'Proteciion'of-tiietighwav and'Tuture,Iliglrivav'Maintenance:;If future'operations or highway
Maintenance,projects by the Town Of Southeld.require an alteration.in,the;position,ofthe utility,,structure,-
• 'or work herein authorized,''or;if,.in the opinion ofthe Highway Superintendent-the work performed under
thisrperinitshall cause unreasonable obstruction-to requiredlhigliway maintenance or-endanger'the health,
' safety'and/or welfare of vehicularpr:pedestri'an traffics 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 permitmay'be-revoked"if the Highway Superintendent finds that'theissuance of the
permit was illegal or,unauthorized orthat the'applicant failed,to comply with any of the terms and
conditions-of the permit or_Chapter 237 of the'Town Code:
4. 'Re`voca`tion ofihe4Permit-bv��the Higliwav`Superintendent:-If the Highway Superintendent"deems it
necessaryto revoke.this permit and the-project-hereby authorized has not been completed,the applicant ,
- shall;"without expense to the•Town and to suety extent and.in-such time and manner asthe Superintendent
may require,remove all Or anyportion of the uncompleted:utility,structure milli and restore the site`to'its
'former condition. ,
5. Notice-ofCommencement: 'Atleast 24 hours prior to commencement of the project,the permittee and/or
contractor.shalLnotify-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,FinaI'
inspection. ,
6. Stora' e"of{Etiuipnient&Materials: The storage Of construction equipment and/or materials shall be
confined within,the'projectwork 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 shalltake all precautions to protect'same. Damage to existing utilities shall be'the
responsibil'ity.of the contractor and:shall be repaired atthe contractor's expense. •
8. Road CIosures:,All scheduled road closures'must'first receive writtenpermission from the'Southold Town
Board prior'to dosing a road., Teniporary 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 aud-start traffic to allow for single lane traffic. Road Closures due to`unforeseen
emergencies require immediate notification.ofthe'Highway Department and shall'be limited to immediate
,and/or expedited restoration of the Work,Zone, . .
9. No-Construction Debrisrin Road:Slioulder-Arca: 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.
• I ,
GENERAL CONDITIONS OF`PERMIT;
APPLICATION/PERMIT'FOR HIGHWA.Y'EXCAVATION AND REPAIR
(Continued)•
• 10.:Install,.Maintain Erosion Controls: Required Erosion Control Measures(Le,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.,CleanFill':Only: All'project°back-fill shall consist of clean sand,gravel or soil'(NOT;asphalt,,slag,flyash,
broken concret'eor:demolition debris):,All:unsuitable soils,excavated at:the site:(i.e.•Clay,,Bog,etc.)areto
be removed•from the site and;not used to backfill-ati'excaVatiori within a Town Highway.
•12. All•.Areas ofSoil•Disturbance:.',All areas of soildisturbance resulting from the,approved 'project shall be
stabilized to the satisfaction'of the Highway-Superintendent immediatelyfollowing project completion. If
tlielproject site.rem-ains 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 conditionslavor
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: Fili`shall
be'placed-inmaximum,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,theRoad 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'oinamental plantings.
Excavations through driveways rand 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 c*repairedby'the contractor•tothe'satisfaction of the
Highway Superintendent.
15. Schematic Plans with-alliTechnical information and'Scope•oi Work:. To reasonably and adequately
'descr'ibe,the proposed work,accurate acheniatic'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'fu'll-depth of;asphalt and/or`concrete pavements. Accuratesize•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.,PavementReconstruction:'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 backfill&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) Instal ecpmpacted'lift of 4"'thick Stone'Blend.base(RCA Blend must meet'NYS.DOT Specification);
d),•Install a two and one half(15")inch compacted lift of Asphalt Base Course;
e) 'Install:a one'and one half(1.5")inch'4of 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. Trenchhitt'of Pavement Surfaces ExCeeding•Cinellundredql0OrrEcet inLehgth: 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'atwo(2")inch lift•of Asphalt'(Type'6j Wearing Course(Typical,shoulder-to shoulder).
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