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HomeMy WebLinkAbout1865 Highland Rd * * * RECEIPT * * * Date: 04/13/16 Receipt#: 202801 Quantity Transactions Reference Subtotal 1 Excavation Permits 1125 $170 00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#34620 $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. 1125 • Permit No. 1 5 RECEIVED TOWN OF HIGHWAY D PARTMENT ��SUFfOL,�c0 Peconic Lane APR 1 3 2016 {. sF Peconic,New York 11958 �rM ' , c �' f (631)765-3140 Southold Town Clerk- ' APPLICATION/PERMIT FOR HIGHWAY EXCAVATION•AND`REPAIR APPLICATION IS HEREBY made to the Superintendent ofHighways 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 excavationprojectherein 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/ANational 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. NameofContractor Phone Number Address of Contractor 3. bt)/ 0 f fip�� �o, Name of Property Owner Requesting Service(if applicable) Address of Owner 4. /t CMOV1 A' RCI — X15 Aiiithy. /y7 l l)/D'Sk k d 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 Sig re of Applicant Application,/Permit.Form is 3//4 4/z4 Required for a complete application! Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the location of all proposedexcavations 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 1 , Block U , Lot CP 7. Starting Date: gat® `tb Completion Date: 1/41`/. 8. Work Schedule: Phase Completion Dale 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: G P 1 l i I 'SC t(' rY 3 4 gra 1.4 /it) ‘ J5 141614' 003177-611_, 65 /e9- 77 ' ag477 D-39 1 of 3 12. Insurance Coverage:(Attach Copy) • (a) InsuranceCompany:,. (b) Policy 11:_ - (c)State whether policy of certification on file with the HighwayDepartment: (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 Checkprovided 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 numberof Project Locations shall be subject to the approval of the Highway Superintendent. Al. ( /Service Connections excavations @$20.00 $ ' 1-0 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 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 �f TOTALS' . �79 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 any)attached her-,to. SUPERINT 04Y •,- ; /1-1'4AY, TOWN OF ,0 •; O VinctMf Q� do Date Date Received by the Town Clerk 41 1511f0 Date Permit Issued L) 13 I (o Permit No. 45 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# 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 IBImproper 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. Permittec's'Contractors to"Comply sitl4erinit-Requirements: .,The Permittee is responsible for informing:its independent contractors,'employees,;agents and-assigns of their responsibility to coniply,with this permit,'including all special/site specific and:general conditions"imposed.by the'Highway Superintendent while'acting as the permittee's.agent with respect'to the permitted'activities,,and such- ', persons sh'a'll be required"to:comply with:all permit requirements. ' . 2. No<Ridlit-to Trespass-orInte'rfere`with Private'Property"Rikhts:,This permit.does-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.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'ot ilie' v� Highwaand.Tuture-Highway:Maintenance::If future operations,or highway maintenance•projects.by the:Town of Southold require•analteration,in theposition ofthe-utility,structure or work'hereinautliorized,or-'if, in the:opinion of=the'Highway Superintendent the.work performed'under this'permit'shall-cause'unreasonabie obstruction to required highway,maintenance or endangertlie 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 perinit,maybe revoked'if the Highway.Superintendent find's 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`-t the lighwav Superintendent:--If the Highway Superintendent deems it necessary'to revoke this permit and the'project•hereby.autliorized has not beencompleted,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. N'otieeof:Commencement:;',At.least'24.hours prior to,commencement-of the 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,conditions'of this permit. Upon completion of the work,the contractor shall provide photograph's of the completed work-to th'e'Town,Highway Department,andrequest a Final inspection. - , ;6. Storage of=E'quipment&"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 Mark-Outs: The;Applicant/Contractor shall be responsible for verification of all'existing utility mark=outs and shall-take all precautionsto'protect,samet 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 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. Read,Closures due to unforeseen emergencies'require'immediate notification of the Highway Department and shalt be liinited'to immediate and/or expedited'restoration'of the'Work Zone. 9. No •.D 'Constructionebris-in-Road_Slioulder Area: All Construction Debris shall be removed;from•thejob _ 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.-Instill;Maintaiir Erosion°Controls: ,Required Erosion Control Measures(i,e.silt fencing)is to be. placed on the downslope edge of anydisturbedarea. This sediinentban ier'is to be put in place before,any disturbance oftheground occurs and,is.to be,maintained in.good functional'condition until thick vegetative .cover is established. '11.'Clean.Fill'Onlv::,A11 project back-fill shall consist'of clean sand,gravel.or soil'(NOT asphalt,slag,flyash, brokenooncrete or"demolition debris). A11'unsuitable soils:excavated at the site(i.e..Clay,Bog,etc.)areto be removed from,the site and,not used to backfill''an'excavation within a Town Highway. , 12.. AILAreas�of:Soil Disturbance: ,All areas,of soil-disturbance resulting'from'the approved project,shall,be :stabilized to die,satisfaction;of the Highway'Superintendent immediatelyfollowing'project completion. ,If ' , the,project'•siteremains;inactivefor_morethan;48hours;or.-plantingissimpractical,due,to,the,season,,,then , , the area shall be stabilized with,straw,hay mulch and/or jute'matting'until weather conditions`favor germination: ' ' ' 13.'13ackfill.&-Compaction titan 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")„inchesthick and,shall be mechanically compacted to a Ninety- -five(95%)percentmaximum dry density. Suitable hydraulic compaction by water jetting at three-foot ,intervals will'also be;permitted subject.to,a projectspecific-approval'by theHighway'Superintendent. 14.'Restoration of Shoulder=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;sprinkier'systems,trees and ornamental,,plantings. ' Excavations through driveways and,private road pavements must-be reconstructed to'meet'all requirement's of Southold'Town Highway,Specifications; All pre-eiisting road;shoulder,improvements that have been disturbed during construction must be replacedor repaired-by the contractor to'the satisfaction of the Highway,,Superintendent. `\ 15..Schematic Plans witti Alt Technical information and Scone of-Work:. To reasonably.and adequately describe'the proposed work,accurate'scheniatic 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/orconcrete pavements. Accurate sizeof bell holes or width of trenching must,be indicated by dimension,or'labeling. This'scliematic'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: Ali Pavement sections must be-reconstructed in the followingmanner;, (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 asphaltbell hole ortrench,'by'twelve(12")'inches,on'all sides; c) Install a compacted lift of 4”thick Stone Blend'base(RCA Blend mustimeet'NYS DOT Specification); d) Install a two and one half(2:5") inch compacted;lift of Asplialt;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 mustfirst be reconatructed'to meet the requirementsof Item # 16 as noted'above. Once all pavement reconstruction is completed to the satisfaction of theHighway .Superintendent;the'entire road section and/or width of road over the eniire'length of trench-'shall be repaved with a two(2") inch'lift of Asphalt(Type 6)Wearing,Course(Typical,'shoulder,to shoulder). SIlq 1 Street Opening Permit Request nationalgrld p gTHE POWER OF ACTION / �!l Work Order Number: Municipality: //b 1174 D ®hc Diz IIgc164-76, Location: /ffi5 ih4i/LAd / 41 / Grid Number: D/r3,/ _a0�-5 Town: ©/ ��( Requested By: 7^ t u A©huf. iviAlSzAdiz- Reason For Opening: , Date Submitted: �� IL A 411.5 SzievieL laylAo14 Number Of Permits Requested For Work: / Return Permit To Customer Fulfillment Description: / ` 7' A $' Ue DL. /Al iii- G`1/See ss A A , OD /V7' N I a 1\cfrs7 1:::**-1" T'.. \V--tr Test Holes As Required As Per UG Utility Mark OutpbL•'� ,�ll/'