HomeMy WebLinkAbout540 Midwood Rd * * * RECEIPT * * *
Date: 04/13/16 Receipt#: 202800
Quantity Transactions Reference Subtotal
1 Excavation Permits 1124 $170 00
Total Paid: $170 00
Notes:
Payment Type Amount Paid By
CK#34610 $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: 1124
Permit No. I I a� , RECEIVED , ._.
TOWN'OF SOUTHOLD •�SgFf01 �;
HIGHWAY DEPARTMENT APR 1 3 2016 1,1,, #.°'.
r: a
°Peconic Lane, ,
Peconic, `r f' °v, .
New York 11958 nA� ' a4,. � �/
(631)765-3140 , Southold Town Cleve : 01;,4;,,-���'",
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION ANDhREPAIR
'
APPLICATION IS HEREBY.made to the Superintendent of-Highways of the Town of Southold for the issuance of an Excavation Permit
pursuant to Chapter 23'7 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'descr'ibed: The applicant agrees to comply with all,applicabllaws,
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. ,
' 'Keyspan Gas:East Corp D/B/A National=Grid
Print or Type
175,
GP ., 3
I. 75 E. Olasd CountermitsryDeRdt'HicBidg:ksville, NFI:Y1 11801
Name of Applicant Phone Number Address of Applicant
2 ,
Name of Contractor ' 'Phone Number Address of Contractor -
7'7
3 fid/ e � ; If IR�1�✓
Name Of Property Owner Requesting Serv''e(if applicable) Address of Owner
5�a /ii'WP 4..d -1/ of�'w/, 61-kids Pi
Work Description and Location(Street Number,Hamlet,'Cress Street)' ,
(a) Is'construction'located within 75 feet of tidal wetlands? *Yes No
ti
*If yes;other Town permits may be required, •
/i /
i
iNOTE: All information requested,by this ignature of Ap cant
,7 '/
Application/Permit Form is !1 / � -
Required for a complete application! � 111
, 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 beforepissuance of a Highway Excavation Permit by the To n Clerk.
V
6. Tax Map-No.: District 1000 , Section \ \ , Block e9 , Lot
7. Starting Date: ,//t(�1 6 Completion Date: \'/f/ /1,6
8. Work Schedule: Phase- Completion'Dalc
Excavation Work Schedul
Facility Installation Must be provi ed
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 Coosst,of Proposed Work: $
11. Remarks: t /ii) (i q 1 it Li '
pit (4.-e ,16 C L (LE -7-- 6ff-
D-39 1 of 3
12. Insurance Coverage;(Attach Copy) '
(a) Insurance Company: - . -
(b) Policy#: .
(c)State=whether policy ofycertification on'file with the Highway Department:
(d)Coverage required extended to the Town:
Any Loss includinkBodilyinjury,property or commercialinjury 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.
Al. ,( - /Service Connections excavations @$20.00 $ D ` v v
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$ /7a
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 C15rk 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 any')attached hereto.
SUPERINTENDEI)IT OF HIGH'1 'S
TOWN OF SOU IO " r K
it
incent Orlando
Date
Date Received by the Town Clerk 14 f 3I `(7
Date Permit Issued ._ u I 1 #I I(D Permit No. ( I 14
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: � 1
Permit#
Highway.Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings.(use code) ApplicantNotified
lst
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' HIGHWAY EXCAVATION AND'REPAIR.
1. Permittec's,-Contr:ictbrs to-Coni•tilv‘witb 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
', Superintendent while,acting as•the permittee'•s'agent,with respect_to the permitted'activities,and such
persons-,shall be r•equired;to comply with all permit requirements.
2. No`-RikhUo-Trespass or'jnterfereWith PrivatePronertyights:, 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,itauthorize the impairment Of any rights;title,-or'interestin real or,personal'p'roperty held or
vested in a person not a party' to the permit. - , -
3. Protection�of tleHigliwaj'-and Future=Highwav'Maintenance:.If future-operations-or highway'
maintenance-projects'-by'theTown of-Southold require an alteration,in the-position of-the-utility,structure
or work herein authorized,or,if, in the opinion of the Highway Superintendent the work,performed under '
•thispermit'shall causeunreasonable'obstructionto'requited-highway maintenance or endanger the health;
safety and/or welfare of-vehicular,orpedestrian 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 tniauthotized Orthat the'applicant'-failed:to Comply'With any of the terms and
conditions-Of the permit or Chapter237 Of the Town
4: ;Revocation of ihecPerntiebv the Highway Superintendent: If the Highway Superintendent deems it
necessary'to-revoke this.permit and the projecthereby 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
.may require,.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 priorto 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 photographs ofthe completed work-to.the'Town•Highway Department and request a.Final
inspection. -
6. Storage:of:Equipment Sc'Materials: The storage of construction equipment and/or material's 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 shallbe 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 goad 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 ofthe Highway
Superintendent.' This'item'will included'but not-be'limited'to'the installation of appropriate signage and
flagmen-to'stop and start traffic to allow'for single lane traffic. Road Closures due to unforeseen
emergencies require immediate.notificationrofthe Highway Department and shalt be limited to immediate
and/or-expedited-restoration of the Work Zone, ' ,
9. No-Construction,Deliris-in Road-Shoulder•Area: All Construction Debris shall be removedfrom the job
site on'a-daily basis.'Alf 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, ,
APP,LICATION/PERMIT FOR HIGHWAY'EXCAVATION AND REPAIR
'(Continued). , ,
' 10.Install,Maintain'ErosionContirols:.Required Erosion'Control Measures(ie'.silt fencing) is to,,be placed
on,thedownslope=edge of any disturbed'area., This'sedimentbarrie'is to be put in placebefore any
disturbance of the ground'occurs,and is to-be maintained in good functional condition until thick vegetative
cover is established.'
'11.`CleanFitl•Only: All project back=fill shall consist of 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 not used to backfill any excavation within a Town Highway.' ' '
12. All Areas of Soil-Disturbance: All,areas of soil disturbance resultiingfrom the approved-projectshall be
stabilized'to the satisfaction of the Highway,Superintendent immediately'following project completion. If
the';,project site remains�inactive,'for more than:48 hourssor,planting is impractical:due to.the season,,then'
the area shall be stabilized,with,str_aw,hay,mulch and/or jute matting-until weather conditions,favor
germination. ' ,
13.:13ackfill•`&;Compaction of altExcavations:,' Back Fill shall,consist of;clean fill pr,soils-which exhibit a
Well-defined moisture,density relationship as determined to-b'e in accordance.with-ASTMD 698. ,Fill'shall,
' 'be'placed:in maximum-lifts'of,twelve'(12"),inches:thi'ck'and'shall,be,mechanically',compadted,to a"Ninety-
five(95%).percent maximum dry density. Suitable hydraulic compaction by,water jetting at three-foot
',intervals'will,also be permitted's`ubject•tb a projectspecifio'approval by'the Highway;Superintendent.
' 14. Restoration of the'Road,Slioulder Area: All man-made improvements,located within existing road,
' shoulder areas',must be protected'to thegreatest'extent practical. Items would'include but not be limited to
driveways&private'road.aprons,'Mailboxes,sprinkler systems,trees and ornamental,plantings.
Excavations through driveways and,private roadpavenients'must be reconstructed to'meet'all'requirements
of Southold'Town,Highway:Spedifications. All pre-existing,road shoulder,improvements that,have been
disturbed during construction mustbe replaced or repaired-by the'contractor to the satisfaction of the
Highway,Superintendent, ,
15.';Scliematie,Plans With alFTechnical,information and'Seone of:Work::'To reasonably'and adequately
describe the'proposed work;.accarate schematic site-plans must-be providedto show'or indicate all"
proposedconstruction,-activity required under this permit., All Pa,emtsurfác,es'scheduled for excavation
mustbe 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 coinpaction'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.lit of 4r thick Stone Blend'base(RCA-Blend must meet NYS DOT Specification);
d), Install,a two•andone'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 mustmeet the-minimum'requirements of the Southold Towi"Highway
Specifications:
17. Trenching,of Pavement Surfaces Exceeding One Aimdred'(100')Feet in Length -Ail-trenching of
' pavementsurfaces,exceeding.100' in length must first_be reconstructed to meet the requirements,of Item
#'16 as notedabove. Once all pavement reconstruction"is conipleted.to the satisfaction:of thesHighway
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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DATE: 4/11/2016 1
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LOCATION: 540 MIDWOOD RD CROSS STREET I: EAS1WOOD DR b0
TOWN: CUTCHOGUE CROSS STREET 2:. HOLDEN�-AVE,
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WORK ORDER: T101831377 ;~
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