HomeMy WebLinkAbout900 Alvahs Ln Permit No.
TOWN OF SOUTHOLD7'224 .
HIGHWAY DEPARTMENT .�� ,' c°��
Peconie Lane . .
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Peconie,New York 11958 %',3,. "• w
(631)765-3140 1
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.
Print or Type 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.
Name of Contractor Phone Number Address of Contractor
19701 f c
3.
Name of Property Owner Requesting Service(if applicable) , Address of Owner
4. 96 #404#3 a-W16 I /POI it4p, AMI) 44
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.
1
NOTE: All information requested by this Sig ture ofAPplica t
Application/Permit Form is r!h/L61/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 Costfof Proposed Work: ,q�$ hat-
(��(� �,�y, / �}��
11. Remarks: ®1 N 1) `i 'ic' t, 4 t t ftJL(/t- N"vim 2J(II� 6 .3t ,16/
D-39 1 of 3
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12. Insurance Coverage:(Attach Copy)
(a). Insurance Company: -
(b) Policy ii:
(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 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 $ 0 Q'
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
TOTALS /17/0
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 w'th
this application and subject to the"General Conditions"and"Special Conditions"of permit('.'any)attac'-1� het to.
SUPERINTE il�j 4:; AY'/
TOWN OF pf.. i , t or y0 �.
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Date
Date Received by the Town Clerk
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Date Permit Issued u0 Permit No. n
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 Departthent
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S-RECORDS'
Inspection Date Findings,;(use code) ApplicanttNotified
1st
3ra ,
46
(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
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GENERAL CONDITIONS OF PERMIT '
' ,' APPLICATION/PERMIT FOR HIGHWAY EXCAVATION ANDREPAIR,
l-. ,Permitt'e"e's Coi tractors to`Comtilyfwitb Pei�m'itRegiiireinenis:. The'Permittee is',responsible for'
informingsits 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-Riahtto Trespass or"Interferewitl'iPrivate-PropertyRiahts:.This permitdoes:notoonvey:to:the
'permitted,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 interest in,real dr'personal property held or ,
;Vested in a,person.not a party'.,to the,peiihit:. ,
' 3: . Pirotection.of ihe`Tlikliwav and'Futore Highway_Maintenance:;If future operations.orhighway
maintenance projects;by the Town,of:Southold require an;alteration,in the'position:of.the utility; 'structure,
or work`herein authorized,or'if;ih the opinion of the Superintendent the,work performed under
thispèrmit shall cause unreasonable°obstruction,torequired highway'maintenance'or endangerthe'health,
safety and/or Welfare of vehicular;orpedestrian traffic;this permit shall`be'revoked-and the utility, '
structure,fill;'excavation,or other modification of thehighway hereby authorized shall not,be,completed.
' , Additionally;the permit may be revoked'if the Highway,Superintendent finds that the issuance of the •
' perin it was illegal'or•unauthorized br that the applicant.failed to.complywith,any of the terms and
conditions of'the,permit or Chapter 237 of thoTown'Code. .
4. Revocation,Of the P,erniitbv'the Hiahway'Sbnerintendent:-, If the Highway,Superintendent deems'it
necessary to revoke this permit and the'projectherebyauthorized has not beencompleted,the applicant '
shall,without expense'to the Town and to.such extent and'in such time and manner asthe Superintendent
' , . 'may require,remove,all,or any portion of theuncompleted 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,-thepermittee and/or
contractor,shall.notify the TownIHighway Department in,writing that theyare.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'cornpletedwork to:the Town Highway.Department and,request a Final
inspection. . .
6. Storageof°Euuiriment&=Materials: The storage of construction,equipment and/ or materials'shall,be
confined within'the project work area.and/oradjacent 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 ail,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 repairedatthe contractor's'expense.
8. Road Closures:" All scheduled road Closures,must first receive,writtenrpermission from the'Southold Town
Board prior to closing,a.road. Temporary laneclosures may,be,permitted'With theapproval of the Highway
' Superintendent. This item will included but not limited to;;the.installation of appropriate signage and
flag men to stop and start,traffic td allow:forsingle lane traffic:-Road Closures due to•unforeseen=
emergendiii"es'requireimmediate notification,of the''Highway Department and shall he limited to immediate
and/or expedited restoration of the Work'Zone,
9. No;Const'ructien Debris.in-Itoad=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 mustbe,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 dal!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;thiek'and shall be mechanically compacted to'a Ninety-
five(95%)percent maximum dry density. Suitable'hydraulic'compaction by water jetting at three-foot
intervals willalso be permitted subject to a project specific approval'by the Highway Superintendent.
.14. Restoration of.thc'Road'Shoulder Area: All man-made improvements located within existing"road
, -.shoulder areasrmu'st be protected to the greatest extent practical. Items would include but not be limited to
driveway&private road aprons,'mailboxes,sprinkler systems,trees and ornamentalplantings.
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 thafhave 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 requiredunder this permit.. All Pavement surfaces'scheduled for excavation
`must,be.saw cut to the full depth of;asphalt and/or concrete pavements;Accurate size'Cf 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..
pecifications.-
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 subbase; ,
b) Over-cut existing asphalt bell hole ortrench 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(2S"):inch compacted lift of Asphalt Base Course;
e) Install a one and one jiff(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. Trenchinit of Pavement Surfaces'Exceedint One`I-Iundred-(l00')Fectin-Lenaih: 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).
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'DATE: 4/2512016 ,r)
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LOCATION: 900 ALVAHS LN CROSS STREET I: MAIN RD •v-I
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TOWN: CUTCHOGUE CROSS STREET 2: COUNTY ROAD 48 (,)
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WORK ORDER: T101835313 r•1
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* * * RECEIPT * * *
Date: 05/02/16 Receipt#: 203848
Quantity Transactions Reference Subtotal
1 Excavation Permits 1128 $170 00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#34743 $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: BONNIED Internal ID 1128