HomeMy WebLinkAboutNew Suffolk Ave (4) * * * RECEIPT * * *
Date: 04/05/16 Receipt#: 202380
Quantity Transactions Reference Subtotal
1 Excavation Permits 1121 $17000
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#34507 $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 FI 1
Hicksville, NY 11801
Clerk ID: LYNDAR
Internal ID 1121
Permit No. 0 RECEIVED
'
TOWN,OF
SOUTHOLD
a� HIG WAY DEpA TM NT e ��o�suFfet��oGy,
� Peconie Lane APR 4 216
Peconic,New York 11'958 � a�
(631)765=3140 Southold ToW Clerk ���
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;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.
Prin!2rTyge Keyspan Gas East Corp D/B/A National Grid
Gas Permits Dept. Bldg: 3 FI: 1
1. Ulr 0a�� a II,Gi B�— �� L4 C)9V 175 E.Old C6unt�ry Rd,Hicksville, NY 11801
— (� -
Name-6f 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. N eW Sut,-M(k, Ave NIS iJr P t ),Sa4r_ IK AvC., 7QQ' W 1.�I.n&r-eq Q lr
'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.
NOTE: All information requested by this 6fignatureofApp ant
Application/Permit Form is `� l
Required'for a complete.application.' 9
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 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: Aen i 1 Completion Date: ,13 j)
8. Work Schedule: Phase Completion Date
Excavation Work Schedule
Facility Installation Must be provided
Backfill&Completion for consideration as a
Pavement ReplacementComplete Application.
9. Under which authority is application being madA e an G a Co (fit -fib a't 160_
See Town Code Chapter 237(E)-Provide Resolution bA or authority from,the Utility Yeing m defied.
10. Estimated Cost
\ofProposeduWork: $
11. Remarks: \ 1 r T J 0i_\
D-39 1 of 3
12. Insurance Coverage:,(Attach Copy)
(a) Insurance Company:, `
(b) Policy#:
(c)State whether policy oftertification 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'orexcavation: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 @$20.00 $ J0; G
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
TOTAL$ � �70s _
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 per t(if any)attached hereto.
SUPERIN EE W YS
TOWN .W RK
1
Vinnt LVI.00ando
Date
Date Received by the Town Clerk
Date Permit Issued �tu Permit No. 1a
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:
Permit# 2 l
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 WorkIn,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. Permittc'e'g Coritra'ctors to'Coinnly witli Permit Reguiremcrits: The Permittee is- ,res'pon' sible for
informing,its,ind'epend"ent contractors,�employees;.agents and assigns of,their responsibility"to'compty.with
this permit; including all special/site'specific arid;general,conditions imposed by the Highway
Superintendent while,actifig•as the permittee's agent with,respect t6 a permitted activities;and such'
persons shall,be,required to comply with-aT er'rnit requirements:
2. 'No'RMihfto Trespass orInterrere4ith.PrivMePi•orierty-"Rikhts;, This permit does not convey.to the
permittee any,,right to trespass upon'the lands of iojacent property•owners•ind order•t'o,perforn'the%0ermitted'
work nor does it authorize the:impairment of any�rights,'title,or-interest in real or personal•propertyheld or
vested,in,a.person not a party to'the permit:"
3. 14oteetiow0f the Highy and future Hipinway'Maintenancev If future;operations;or highway'
maintenance,projects by the Town,of-Southold:-require an,alteratiomin-th'e position of the=utility,structure,
or work•herein authorized,or if,in'the opinion ofthe Highway'Superintendent the work performed under
this permit'shall cause unreasonable obstruction to required'highwaynraintenance'or endanger-the health,
safety and/or welfare of vehicular'or'pedestriaii 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-thai the applicant failed to,complywith any of the terms and
conditions of the permit or Chapter 237 of the Town Code.
4. Revocation�of�the Permit`byr,tlie'Hikhway Suneriutend'ent _If the Highway Superintendent deems it
necessary to;revoke-this permit-and the projecthereby authorized has not been completed,the'applicant
shallwithout 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. Notiec,of Comriiencement:,At least 24 hours priorto commencement of tha 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,conditionsof 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. Storag6JAEquipment&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 nbrmal`highway traffic.
'7. Uti IW,10ark=0utsr The Applicant/Contractor shall be responsible for verif cation:of all-existing utility
mark-'out's and shall'take all precautions to protect�same. Damage to existing,utilities shall be the,
responsibility ofthe,contractor and shalLbe'repairedat,the 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 maybe permitted with the approyal'of the,Highway
Superintendent. This item will included but not be-lirriited'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 theNghway Department and.shaltbe limited to immediate
and/or:expedited restoration of the Work.Zone..
9. Mi-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.
GENERAL CONDITIONS-OF PERMIT,
APPLICATION/PERMIT.FOR HIGHWAY EXCAVATION AND REPAIR
(Continued)
IO.,:Iiistall;,Maintain�Erosiari Controls: Required Erosion Control Measures(i:e.silt,fencing)is,to be placed `
on.the:downslope edge of any,,,disturbed area. This sediment l atrier is to'be put in place before any
disturbance of the,ground occurs and is to be maintained-in good functional condition until4hick vegetative
cover is established. ;
1 l.-`Clean M',0n1y:, All,-'preject back-fill shall consistof clean'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 hot used to b'ackfill'any excavation,within a'TownEighway:
12. AII,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 impracticaLdue'to the,season,then'_,,,
the area shall be stabilized with straw,.hay`mulch,and/or jute'matting until weather conditions favor
germination.
13.,,Backiill&-Compaction of iill,Exeavations , Back Fill shall,consist ofclean fill or,.soils which exhibit&
well-defined,moisture densityrelationAip,as determinedto-be in.accordarice withASTMD 698. .Fill shall
be,pl'ace ;ih maximum lifts'of twelve(IT')inches.thick and,shall be mec]ianically,compacted"to a Ninety-
five(95%0)percent maximum:drydensity. Suitable,liydraulic compacti'on by'waterjetting atthree-foot
intervals will also be permitted subject to a project specificapproval;'by the Highway,Superintendent.
14.Restoration ofahe'Road Slioiilder'Arca: 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 alffe'quirements
of Southold Town Highway,Specifications; All pre-existing,road'shoulder,improvemerits that have been
disturbed,during construction'must be replaced or-repaired by the contractor to the'satisfaction of the
Highway,Superintendent.,
15.),Scliematir Plans-rvith all Teeltnical information and'Scone•of Work:, To reasonably.and 'adequately
describe'the,proposed work,accurate'schematic site,plaris'must-,be provtded.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 asphalt7and/6r concrete pavements. Accurate-size of bell holes or.width
of trenching must be,indicated by,dimension or1ab'eling."This schematic'site'plari inusfprovide'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 exi'sting.asphalt,bell;hole'or'trench by twelve(12")inches on all"sides; ,
c).Install-acompacted'liftof 4"thick Stone'Blend;base(RCA,Blendmust meet NYS DOT Specification);,
d), Install,a two',and'one half(2.5')inch compacted lift of Asphalt Base Course;
e) Install,a brie and one half- 1.5") 'inch�of Asphalt(Type 6)Wearing Course.,(ProvideAC at all joints)
All work,listed herein must meet.the�minimum requirements of the Southold Town Highway
Specifications.
17. Tkenchinz.of Pavement Surfaces Exceeding One Hundred if]001Feet-in Leng-thu, 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 10 the'satisfaction-6f 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).
SI►y
national: r ,
N
a; PERMIT "MI CATION SICE T.CH M
Village.Of
MATE: - 129/2016
�n
LOCATION: NEVA SUFFOLK AVE moss sTREET I: AIRWAY DR o
TOWN: MATTITUCK CROSS STREET 2b, cd
`wmK-,oRDER.- 7101366927
N
It
,5
Vn
STMACE:
'Macadam.Ro d
¢ Q
0
a�
cl•
CL
ci
;17-
on
700,
cd
4'x 4' ell Hole
NEW SUFFOLK AV NS �
3
Q,