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• Perrnii No. _1 lI a.,6 r-'
TOWN OF SOUTHOLD • ,oco ;;
HIGHWAY DEPARTMENT 64,
Peconic Lane
Peconic,New York 11958 c+
(631)765-3140 'yo/ 410,./
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION 1S 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 the excavation-he.rP-in ri. rriharl Th+. ^•-•-ly with all applicable laws,ordinances,codes and
regulations,the attached..G�Long Island Lighting Company d/b/a !ns",if any and to permit authorized inspectors to make
necessary inspections of the LI PA through its agent, Long Island
Electric Utility Servco LLC and PSEG
Print or Type Long Island 117 Doctors Path
1. Riverhead, NY 11901
Name of Applicant — Phone Number Address of Applicant
Name of Contractor Phone Number Address of Contractor
3. $ e
ne of ropert wr er R ue ting Service(if applicable.) dd f• Ct�rCro L
c�c ��j�x . R 1� � e ��1 f I ,.., � �"
4. _ _ '� -- b r�_11 c. �� hoz_ }►11 ro' _1� o?C rj v 1 eLc��� lf� F-MIK
Work Description and Location(Street Number,Hamlet,Cross Street) tom,
(a) Is construction located within 75 feet of tidal wetlands? * Yes No
*If yes,other Town permits may be required.
,t /411111.°
NOTE: All information requested by this "Signature of Applicant
Application/Permit Form is //6
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 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. T Completion Date:
8. Work Schedule: Phase Completion Date
Excavation Work Schedule
Facility Installation Must be provided
Backfill&Completion —__ for consideration as a
Pavement Replacement _ Complete Application.
9. Undei which authority is application being made:
See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified.
10. Esti mated Cost of Proposed Work:
11. Re marks
D-39 1 of 3
Soo/fool XY.a Z6 I141 VTOZ/OZ/90
•
12. his mance Coverage:(Attach Copy) -
(a) Insurance Company:--- .,_,,__ .--- -
(b) Policy tt•:
(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$2,000,000 general aggregate.
13. Securit y:
(a)Surety Bond or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided:_ �_—2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee $150.00
A 1. - S /Service Connections excavations®$20.00 $_zee%0 0 —
N o.�
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 I)920 /_L.F.@$0.30 $_ G QC) . 0.._
D. Excavations 5' in depth and over
0-100 L.F.=$50 00;Additional L.F.@$0.50 $
E. Utility Repair Excavations a $10.00 $
No.
Repairs same service @$5.00 $_
Additional Q
TOTAL$ 856.00
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 Vastly)attached hereto.
11 N0121 ?OJV�L. bIZtLCING- oML y it SUPERINT : DENT OF HIGHWAYS
TOWN OF .OUTHOLU L` O
PLC- Ndw . ,!tJe (3),)T
F//. .4 A' L.....
m"cent M. •rla o
late
Date Received by the Tow! Clerk t-( I ( .((� �_
Date Permit Issued 4 kill�D
Permit No. 1 ` ()—("
NOTE: Permit expires one(I)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.
1)-39 2 of 3
SP/
SOO/3000 Via ZS:6 Did tTOZ/OZ/90
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Copy Distribution:
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk (Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1"
2"
3rd
4th
(To Permit Clerk)
REMARKS
CODE
13 improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure(due to backfilling)
BUC Building Under Construction
W1P 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
sJ/y
Soo/£oolj XK5 £S:6 I2id VIOZ/OZ/90
.
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
1. Permittee's Contractors to Comply with 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 required to comply with all permit requirements.
2. No Right to Trespass or Interfere with Private Property Rights: 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
vld-m a person not a party to the permit.
3. Protection of the Highway and Future Highway Maintenance: If future operations or highway
maintenance projects by the Town 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
this permit shall cause unreasonable obstruction to required highway maintenance or endanger the 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 permit may be revoked if the Highway Superintendent finds 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 by the Highway Superintendent: If the Highway Superintendent deems it
necessary to revoke this permit and the project hereby 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 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 photographs of the completed work to the Town Highway Department and request a Final
inspection.
6. Storage of Equipment&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 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 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. Road Closures due to unforeseen
emergencies require immediate notification of the Highway Department and shall be limited to immediate
and/or expedited restoration of the Work Zone.
9. No 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)
10. Install,Maintain Erosion Controls: Required Erosion Control Measures(i.e. 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. Clean Fill 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 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 impractical due to the season,then
the area shall be stabilized with straw, hay mulch and/or jute matting until weather conditions favor
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. Fill shall
be placed in maximum 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 the Road 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 ornamental plantings.
Excavations through driveways and 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 or repaired by the contractor to the satisfaction of the
Highway Superintendent.
15. Schematic Plans with all Technical information and Scope of Work: To reasonably and adequately
describe the proposed work, accurate schematic 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/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 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) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification);
d) Install a two and one 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 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 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 a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical, shoulder to shoulder).
* * * RECEIPT * * *
Date: 04/18/16 Receipt#: 203067
Quantity Transactions Reference Subtotal
1 Excavation Permits 1126 $856.00 ,
Total Paid: $856 00
Notes:
Payment Type Amount Paid By
CK#9000014508 $856.00 P S E G, Long Island
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: P S E G, Long Island
117 Doctors Path
Riverhead, NY 11901
Clerk ID: BONNIED Internal ID 1126
1 2 3 4 5 6 7 a 9 10
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D MAINTENANCE AND PROTECTION OF TRAFFIC PLAN
SHORT-TERM STATIONARY OPERATION INVOLVING SHOULDER CLOSURE
(PAVED SHOULDER 8 FT.OR WIDER ON URBAN TWO-LANE
CONVENTIONAL HIGHWAY_
FOR HORIZONTAL DIRECTIONAL DRILLING
SCAR 1--612
NOTES
1 NPT SCHEME DEPICTED HERE APPLIES TO THE HORIZONTAL
' DIRECTIONAL DRILLING OPERATION
E 2 OPT SCHEME SHOWN HERE IS BASED ON MUTED TYPICAL
- APPLICATION TAST-C4U(SHORT-TERM STATIONARY OPERATION
INVOLVING SHOULDER CLOSURE(PAVED SHOULDER B FT OR
SIGN LEGEND LEGEND WIDER ON URBAN TWO-LANE CONVENTIONAL HIGHWAY))
3. MPT SCHEME WAS DESIGNED BASED ON 40 MPH SPEED LIMIT
CONTRACTOR TO VERIFY EXISTING SPEED.LANE WIDTH.AND SIDE
STRDESISIINATION SIZE SIGN //�///� Mb®A¢ARTA PER ENYSDOT ETS CONDITIONS.CESSAORYAD,NST TAPER AND BUFFER LENGTHS
///////� 4 IN PLACE'ROAD
E OF INTERSECTION
SIGNS ON SDE ROAD 100-200 FT
111/204 38106• O • 5 REFER TO LANE CLOSING RESTRICTION PUBLISHED BY NYSDOT
00110 FOR LANE CLOSURES
6 REFER TO MUTED FOR SIGN SIZES COLOR AND TEXT
7 CONTRACTOR SHALL ALLOW ACCESS DROVER WORKSPACE FOR
. sw SIDE STREET TURNING MOVEMENTS
ND
G20.2 38Y18° •
ROAD WORK .,
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. PERMITTING PURPOSES ONLY-NOT FOR CONSTRUCTION
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