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Home My WebLink About360 Sunset Ave * * * RECEIPT * * * Date: 04/22/16Receipt#: 203318 I Quantity Transactions Reference Subtotal 1 Excavation Permits 1127 $170.00 Total Paid: $170 00 Notes: Payment Type Amount Paid By CK#346666 $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 1127 Permit No. I I Z, TOWN OF SOUTHOLD. , RECEIVED „,,, ' HIGHWAY DEPARTMENT , SUFfet,tc°G�, •Peconic LaneAPR 2 0 2018 '' `.':'k., Peconic,New York 11958 `” ''`' (631)765-3140 •�.* 4G 4°T Southold Town 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 Ybrk,,arid,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. Print or`Ty� Keyspan-Gas East Corp D/B/A National Grid Gas Permits Dept. Bldg: 3 Fl: 1 • 175,E. Old Country Rd'Hicksville, NY '11801 Name Of Applicant Phone Number Address of Applicant 2. �1 o 7761 ?� oz 667 Name of Contractor Phone Number Address of Contractor 3. Name of Property Owner,Requesting'Service(if.applicable) Address of Owner 4. 3e0 ,5V114�-T c T1 irime --t 3E0/ 610 HA-(1) d Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. did/72,4th-NOTE: All information requested by this Sre of pplicant 1 Application,/PermitTorm is 4/46 - / �� / 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: Completion Date: 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 ofProposed Work: $ 11. Remarks: BI L� ` v F' ' /'U RED- rttL iv g 6 L I E 70 prtNr D-39 1 of 3 • 12. Insurance Coverage:(Attach Copy) (a)' Insurance Company: (b) Policy#: (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$2,000,000 general aggregate. 13. Security: (a)Surety.Bond or Certified Check • provided in the•total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for,Applications,and permits: Basic ApplicationTee 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 $- O.d e X 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$ //�' ®D 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 eto. SUPERIN • ' i E ' • e WAY,/ • TOWN't L• • n /W YO/r ' t M.Orand j6 i �1,, ate Date Received by the Town`Clerk 14aV (p Date'Permit Issued, 4192\ (r Permit No. 1 1 Q 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 . nationalgrid c.i a PERMIT APPLICATION SKETCH Village Of ii DATE: 4/15/2016 d- LOCATION: 360 SUNSET AVE CROSS STREET-1:, MAIN RD 3 cr ,TOWN: MATTITUCK. CROSS STREET 2:, MARRATOOKA LN M WORK ORDER: T101,832667 N I SURFACE: j 3 Macadam Ro.d� Hougeqqa CIX 360 .z Q 0ix cd FP Q" as opo of r 4PI cal 350' — cd 4'x 4' Bell Hole U 0 of N SUNSET AVE , ..or— �7 6 R • Copy Distribution:, Permit# ( .L 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/P-ERMIT,FOR HIGHWAY'EXCAVATION AND,'REPAIR 1. PermitteeContra''ctars to'Comply'withPermitilequiremenis: 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''agent'with respect•to`the,permitted activities,,and such ,persons shall be;required to comply with all-permit requirements. '2. ,No Riglit to.Trespass,or'Interfere.ivithTrivate,Pronerty-Riahts:,This permit does not convey to,the permi'ttee•,any;right to,trespass-upon'ahe'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 in a person not a party.. to 'the permit: ' ' 3. Protection:of-the Highwav and'Future-IliQhway'Maintenance:,'If future operations highway ' ' maintenance projects'by-the Town,of Southold require an alterationain.the position.of.the-utility,structure„ or;work,herein•authorized,,or it,in the.opinionofthe Highway Superintendent the work performed under thispermit: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 oftthe-highway hereby'authorizedshall notbe 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 oihe=Perm fitbv:tlie Hithwav'Superintendent:- If the Highway Superintendent deems it necessary'torevoke this permitandtheproject hereby authorized:has not been,completed,the applicant shall;without expense to the Town,andto,such extent and'in such time and'manneras the Superintendent may,require,remove all or any portion•of the uncompleted:utility,structure or fill and restore the site'Wits 'formercondition. , '5. Notice'of Commencement: .At least 24 hours prior,to commencement of the,project,the permittee and/or contractor.sliall'notify the Town Highway Department in writing that theyare'fully aware of and understand all terms.and project conditions of this permit. Uponcompletion of the work,the contractor . shall,.provide.photographs of the completed work to-the Town Highway,Department,andrequest a Final inspection. , '6. Storage ofEquipment-&'Materials: The storage of construction equipment and/or inaterials''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 proteasame. Damage to existing-utilities shall-be the responsibility of the contractor and shall be repaired at the contractor's'expense. 8. Road CIosures:,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 notbe'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 Const ruction'Debris,in•Road-Shoulder-Arca: All-Construction Debris shall be removed'froth'the job site on aadaily basis. All'stockpiled soil as well as all other project materials,that will be staged within the Right-of Way mustbe.delineatedwith 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 placebefore any , disturbance'of the'•groundoccurs'and•is to be maintainedin good functional'condition until thick vegetative • 'cover is established., , , ' 11.'Clean�I+ill'Onlyr All project'back=fill shall consist of clean sand,gravel or soil(NOT asphalt,'slag;flyash, 'broken concrete,dr demolition debris): All,unsuitable soils;excavated atthe site_(i.e.Clay,Bog,,etc.)are to be removed,from the site,and not.used to backfill•any'excavationwithin a Town Highway. 12. AllAreas of'SoirDisturbance: All areas of soil disturbanceresulting from 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 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.,Backbit&'Compaction of all Excavations:. Back Fill shall consist of clean,fill,or„soils which'exhibit a well-defined as determined tote in accordance with ASTMD 698. Fill shall 'be-placed ii maximum_lifts of.twelve(12")incheslhick and shall be m'echanically compacted to a Ninety-' five.(95%)percentmaximum dry-density. Suitablebydraulic compactianby,`,water jetting at three-foot ' intervals will also be perm ittedsubject to a project specific approval by the Highway'Superintendent. ' =14.;