HomeMy WebLinkAbout1125 2nd St 2 Perrrfit No. QD
HIGHWAY D PA TM NI UTHOLDggFFOt�-�o�y
Peconie Lane
Peconic,New,Yoilc 11958 v•
(631)765-3140
APPLICATIONJ 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,'add 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", !f any and to permit authorized
inspectors to make necessary inspections of the job site.
Print orType Keyspan Gas East•C&P'D/B/A National Grid
Gas Permits Dept: Bldg: 3,FI: 1
1. 1,75,E. Old C®untry,Rd Hicksville', NY 11801
Name of Applicant Phone Number Address,of Applicant
2.
Name of Contractor Phone Number Address of Contractor
3.
Name of Property-Owner Requesting Service(if applicable) Address of Owner
11
4. ���`� Ol�� ST/vW�vt'�BL�' �� ��pC N`0 �Mly �,
Work Description,and Location(Street Number,Hamlet,Cross Stre t)
(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 Sign re of Applican
Application/Permit,Form is ,Required for a complete application! IvIuT t (y
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 ,qq Section Block Lot nn
7. Starting Date: �9p`- 1 I(�, Completion Date:
8. Work Schedule: Phase Coin Piet iim',I)aie
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: ®� 1" C 1 ��� Idrt/L�i �Q T�3T�1
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 Application Fee for Each Project Location - $150.00
A Project-Location would include'each:B'ell 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 $
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations,19"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$ / ® r
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 it(if any)attached hereto.
SUPE&FT
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TOWO D
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Date
Date Received by the Town Clerk , I V
Date-Permit Issued 6 Permit No.
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
.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' I 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. Permittce's'Confractors to''Cain»Iy'witli=Perniit-Reguiremcitts:_ The Permittee,isresponsible,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 perrnittee's agent with respect to the permitted activities;and such,
persons shall'be,required'to comply with all,permit'requirements.'
2. N&'Rikht to-Trespass or Interfere withPriVate Property=Riahts ,,This permit,does not convey,fo the
permittee any right to trespass uponthe-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. Proteeiibn of iller HijfiwAv,aii&P1uture highway Maintenance:_If future.operations or•highway
maintenance projects by:the Town of Southold'require'an alteration inthe,gosition'of the utility,structure
or work'herein authorized,or,if;in the opinion,of'the Highway.Superintendentthe,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,f ll,excavation,or other modification'of the.highway hereby authorized shall not be completed.
Additionally,'the.permif 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 df thePerhiJfbY the'High*ay'Sunerintendent: If the Highway Superintendent deems it_
necessary to-revoke this permit-and the proje'rVhereby authorized hast ot:been completed,the applicant
shall,mithout 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,Commencemient: ,At least 24 hours,prior,to commencement.of the project,the permittee and/or
contractor shall"notify the Town Highway Department in wriiing 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 completed4ork to the Town Highway Departm'entandrequest a Final
inspection.
6. Storaze of EW'Pn ent&'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
responsibilityofthe.contractor and,shaTbe repaired'atthe,contractor's expense.
8. Road Closures:,All scheduled road closures mustfirst 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,riotification;of the'Mighway Department and'shall,be limited to immediate
and/or,expedited restoration of the Work Zone,
9. No•Construction,,Debris imRoad 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 musfbe delineated with reflective signage or other means to,meet the minimum requirements
of the NYS DOT Construction Standards.
` ,}
GENERAL, -OF PERMIT,
APPLICATION/PERMIT FOR-HIGHWAY;EXCAVATIONAND REPAIR
(Continued)
10. Install;,Maintsiin`ErosionTControl's: 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.
1 l,,!Clean'Tih Only: All,project back=fill,shall consist of clean,sand,gravel or-soil'-(NOT asphalt,slag,flyash,
broken:,concre'te'or,demolition debris): All,unsuitable soils excavated'at,ihe site,(i:e.Clay,Bog,,,etc:)-are to
be removed from the site and not,used to'backfill'any excavation within aTownHighway.
12. ARA Ireas'of Soil Disturbance`: All areas of soil disturbance resulting from,the approved project,shall-be
stabilized-to the.satisfaction`of the Highway Superintendent iinmediately-following projectcompletion. If
the,project site,-remains inactive.for more than 48 hours�or planting'is,iinpractical due to the,season,,th'eri
the area shall be:stabilized.with straw,hay jnulch,and/or jutd�matting'until weather,conditions favor
'germination.
13.:I3ackfrll'&&Carriiraction of'nll'Excavntions:_ Back'Fill.shall consist of clean fill or soils which exhibit.a
well-deftnedmoisture,density relationship as determined to be inaccordance with ASTMD 698. Fill shall
be placed in,maximum.lifts of,twelve(l2")rinches,thick and,shall'be mechanically compacted to aiNinety-
five(95%)percent maximum,dry density. ,Suitable hydraulic compaction,by water jetting at three-foot
intervals,will,also be permitted subject-to a projec'tspecific approval by the Highway'Superiritendent.,
14.'Re-stora'tion,of tlieRoad,Sitoulder Area: All man=made improvements'located within existing road
shoulder,areas'must be protecte&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.
Excavationsthrough driveways`,atid,private road'pavements•rriust''be'reconstructed to meet all requirements
-of Southold Town'Highway,Specifications. 'All pre=ekisting•road,shoulder,improvements thatbave;been
disturbed`during,construction,must.be replaced or-repaire&by the contractor to the satisfaction of the
Highway,Superintendent.
1,5.'Scbematic'Phins,'►with,,all'Teclinicahinformation.and'Seone ofVbrk:, To reasonably,,.and adequately
describe`th&proposed wo&,`accurate schernatic.site plans,mustbe provided to show or indicate all
,proposed construction,activity-required under this permit: Al1'Pavement'surfaces'sch'eduled for excavation
must be saw cutto the-full�,dep"'th 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 requirement sfound:in the
Southold Town Highway Specifications.
16.'Pavement Reconstruction:'All-Pavement,sections,must bexeconstructed in the following manner;
(Note:When ConcreteTavements 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 existingasphalt bell hole'or trendh'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 tworand'one half(2:5")inch compacted°.lift-of Asphalt Base Course;
e) Install.a one andone-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.,
17.7rencltine,of,Pavement Su'rftces Exceeding One Hund'red'(I0W)Teet in,L'ebotlr:, 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 ofroad 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: 612412016
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LOCATION: 1126 2ND ST CROSS STREET 1: KING ST
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TOWN: NEW SUFFOLK ,CROSS STREET z: ORCHARD ST �¢
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wmK ORDER: T101845408
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* * * RECEIPT * * *
Date: 06/02/16 Receipt#: 206359
Quantity Transactions Reference Subtotal
1 Excavation Permits 1132 $170.00
Total Paid: $17000
Notes:
Payment Type Amount Paid By
CK#34982 $17000 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
Bid 3 FI 1
Hicksville, NY 11801
Clerk ID: BONNIED Internal ID: 1132