HomeMy WebLinkAbout2300 Village Ln l
Pernut No. �
H GHtiVAOY DEPARTM NT ��o�p'��FFOI,�coG��
Peconic Lane �� .
Peconic,New York 11958 �o �; �
T101864681 (G3])765-3140 �,�a.1 � �,a°�
APPLICATION/Pf;RN1fT sOR HiG1i�VAY TXCAVAT[QN AN1]Ri'sPA1R
APPLICATION IS HEREBY mnde to d�e Superintandent of H3gltways of the To�vn of Sauthold far Ihe issuance of an Excavntion Permit
pursuant to Cl�apter 237 of the Code of Ihe To�m of Southold,Suffolk County,New York,and other upplicabie laws,ordinnnces or
regulutions for ench individunl contiguous excnvation praject tiereIn dcsaribed, The applicaot agrees tn comply�vith a11 app{icable law>,
ordinnnces,codes nnd regufations,the Attnched"General Conditions of Perrnit"ottd"Speaial Conditions",if nny and to�crmit uuthorized
inspectars to make necessary inspections of the,job site.
Printor'i�vn� Keyspan Gas East Corp D/B/A Natianal Grid
Gas Permits Dept. Bldg: 3 FI: 1
�. Margaret Paglia 516-545-4094 175 E. 9{d Country Ftd Hicksvilte� NY 11801
N�me of Applicant Phone NumUer Address ofApplicani
2.
Numc of Contrnctnr Pitonc Numbcr Address of Contrnctor
3.
Namc of Property O�vner Rec�uesting Service(if npplicable) Address of�wner
� 2300 Village Ln- e/s Village Ln, 55' s/o Willow St
�Vork Description and Location(Strect Number,Hamlet,Crass Street)
(n) Is construction located�vitbin 75 i'eet of tidnl ti4etlands? "Yes,,,,_ No
*If yes,athcr Tnwn perm its may be rcquired. + -
NOTE; All informption requcsted by!i►is ignatura of Ap cant
Applic�tion/➢'crmit T'orm[s
3tequlred for a camplete applicntlonl July 25, 2016
� • DAte
S. (n) Altached plot pl�n to reasonably and Adec�uate{y describe the proposed�vork, Provide nccvrate schemaEio site plpn sliowing the
IocaHon of nfl proposed excavations nnd relationship to adjoin9ng premises,public strcets or nrcas,nnd give u detailed description of
nll sita nnd puvement resto�ation�vork.
{b) Attach ull otlyer necessary permits and licenses t'or this project.
(c) 1�Vork covered by tliis application may nol commence before is�ttance oP n FIighwny Cxcavation Aermit by the Town Clerk.
fi. T�C Map Na: District 1000 , Section�V � IIlock l . L.oc 1 °' 1
7. StartingDate: �U�y 22,2016 CornpfetionDpte: August 22, 2016
8. �Vark Sel�edule: Phnse Cotnnleli��n[};tite
EXCaVAtiOri Vnr c Sc1ie u1c
Cacility Instfllfation A�ust ve pravide�
Bnckfill S Completion for conslderatian as A
Puvement Repiacement Compicte Appllention.
9. Under which nulharity is application being made: Keyspan Gas East Corporation d/b/a National Grid
See Town Code Chnpter 237(E)-Provide Rcsolution by,ar nuthority i'rom,ilie Utility bein�mndified.
10. Estimated Cost oCPropased�Vork: S s�__ ,�„� , ,��..�.____,-
1 l. Remarks: �1) 4' x 4' Bellh�ole road opening �
D-39 1 of 3
12. [nsurance Coverage:(Attnch Copy)
(a) Insur�nce Company:,
(b) Potiay#�:
(c)Stntc whcthcr poticy oFcertificntion on fiic with the Hightivuy Deparimerit:
(d)Coverage required extended to tlie Town:
Any Loss inciuding Sodily injury,property ar commercial injury coused by or uttributable ta tlte work performed:
�1,000,000 per Occurrence nnd S Z,OOQ,000 general aggregate,
13. Sccurity:
(p)Surcty Bond or Certif:ed Check provided in the totul Amount of$
(b}Maintennnce Bond provided: 2 ycnrs or 3 years.
14. Fees for Applications and permiis:
Basic Applicutian Fee for Eech Project Locntion - $150.04
A Project Lo�ation tivould include eacb Bell Hole and/or every road apen9ng or excavation within any
SO'Radius whether or not tliey may be inter-�onnected by open trench or directionn!borin�,
The total numbar'of PraJect Locations shnll be subjeet to tlie upproval of the Hi�hwny Superintendent.
A1. � /Scrvicc Connections excnvations Q�20.40 g 20.00
No.
A2, /Additional Excnvatinns same service Q S l Q.00 S�
Na.
8, Excavatians 18"in deptli or fess .
Q-100 L.F.=$1Q.06;Additinnal L.F.Q$0.10 $ _____-_._._
C. Excavations 18"in depth to 5' in depth
0-100 L.F._$30.06;ABditionAl L.F.Q�0.30 S
D. Excnvutions 5'in depth and aver
0-100 L.F.=�50.00;Additiona! L.F.Q�O.SO $
E, Utiliry Repair Excavations Q$]0.40 � •
No.
Repai�s same secvice Q$5.00 $
Additional
�oTALs 170.00
F. Notice to public utilities proaPmust bc provided and
Shu11 be�ttached to this applicAtian prior to issnunce of perrnit.
• r � � * . * � � rt t � � t
Authorization is hereby granted to the Tawn Clerk of tl�e Town of Southold to issue a Higlitvay avution permit to:
in accordancc�vi
this applicatian and subject to tEte"GeneraS Conditions"und"Special Conditions"of permit ' uny) nched o
SUPERINT E A 5
rowrr or• s ,N�W K
lnc t fanc�,o� r�
�
pate Received by ihe To vn lerk
R 1 D�tc
Date Permit lssued � Permit No. ���
NOTE: Permit expires one(1)yeur from date of issuance.
No work to stnrt�vilhoot 24 haur naiice to Superintendent of Hi�hways.
Permit musi 8e nvailaUle at all times far inspection,on site,duriog construction.
D-39 2 of 3
Copy Distribution: ` rf
Permi## \ `��
Highway Departrnent •
Engineer(witli page 3}
Applicant
Tawn Clerk(�riginal)
INSP�CTOIt'S ItECOItIDS
Inspeck'son Dat� Findings(use code) Applic�nt Notified
isc
2nd
3ra
4m
, (To Fermit Clerk}
RE�
CODE
IS Improper Barricades
[L Improper Lights
ST Sunken Trench ar Exeavation
UTM Unuble to Measure(duc to buckfiltin e�
BUG Building Under Conswction _
WIP Wurk In Progress
DB improper Backfitl(too high,noi sufticicnt)
HFS Inspector Holding for Final Settlement of ExcavAtion
RFR Ready for Repair
D-39 3 of 3
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GENF.RAL CONDITIONS UF P�RMIT �
. APPLICATION/P�RMIT FOR HIGHWAY�XCAVATION AND REPAIR
l. Pcrmiitec's Cautrnctars to Comnlv�vitli Pcrmit Rcauirc�nen[s: The Permittee is responsiblc for
infarining its indepondent contractofs,employees,agents nnd assigns oftheir responsibility to comply with
this permit, including aII spec'saUsite specific and�encral conditions imposed by the Highwuy
Supar'sntendent while actin�ns the�permitiec's agent with respcct to the permitted nctivities,And sueh
' persons shull be required tp comply with all permit requirements.
2. No Ri fit ta�Tres �ss�r TnlcrPerc�vilf�Privatc i'ro cr Ri Iiis: This permit does not convey to the
permittee any right ta trespass upon`the lands nf adjacent property owners in order to perform ihe permitted
�vork 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 purty to the peiniit, -
, .
3. Pz'O�CC1Ipi1 Ol lfiC UI�IIlY1v aad Tuturc ITielrn�av Mnintenance: If futuie operations or highway
� m�intenance pra}ects by the Town of Southoid requirc an alteration in the position af thc utility,structure
or work hercin authorizcd,ar if,in tlie opinion of the Hi�hway Superiniendent the work peTi'ormed under
. this permit shall cause unreasanab(e obstrucEion to rcquired highw�y maint�nance or endan�er the heASth, ,
safety and/or�velfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility,
structure,fill,cxaavation,ar other modif cation of the highwny hereby authorized shai't not be complsted.
Additionally,the perm'st may 8e revokcd if the Highway Superintendent fnds that the�issuance af the
permit was iliegal or unnuthorized or that the applicAnt failcd to comply with nny of the terrns and
conditions of!he pecmit or Chapter 237 of the Tnwn Code.
4, Revocaition of thc Permit bv tT�c I�Iieli�vav Sunerintci�dent: If the Highv►iay Superintendent deems it"
necessary to revoke this permit and_the praject hereby uuthoriz�d hu.s not been cornpleted,the applicant
shull,withoui expease fo the Town und to such extcnt and in suoh time and manner ns ihe Superintendent
mey rcquire,remavc�a11 orany partion of the uncompieted utility�struature or fill und resiorc the site to its
former conditian. ' •
5: Naticc of Commencement: At le�.st 24 hoars prior to commcncement of the project,tha perrnittee and/or
contractor shall notiiry the Town Highway Department in writin��that theyurc fuily awnrc of aad
understnnd all ierms uitd project conditions af tiiis pernti� Upon completion of the work�the contractor
� shnl!provide photogruphs of the completed work to the Town Highway Department and request a Final
' � inspeotion. . ,
- 6. Stornee oi I�:ctuiomcnt&Mntcrin�s: The storage of construction equipmcnt endlor materiais shall be
� confined within the project'wark area andlor adjaccnt areus where permission/legal access has been
obtained in n m�nner that docs not interfere�vith normal high�vay t�ffic.
�, Utilitv Mnrlt Outs: The Appiic�nt/Coniractor shal{be respons'sble for vcrifcutian of ul1 exisling utility
mark-outs aad sh�ll take all pTecautions to protect same, Damage to existing utiliEies shall be the
respansibility of the contrsetor and shal!be repuired At the contru'ctor's expense.
- 8. Road Ctosures: All schcduled roud closures must first reccive written permission from the Southo[d Town
Board p'rior to closing a roi+d. Temporary lane closures may be permitted,�vith the approval of the Highway
} Superintendent. This item will included but aot be limited to the in"st�►Iiativn of appcopriate signage and
� fl�g men to stap and star!traf�c to allow for single lane traffic. Road Closnres due to unforescen
' emergencies require immediate noiificution oFtfte Hightivny Department and shall be limited to immcdiate
und/or expedited restaration of the Work Zone,
9, No Consiruction Del�ris i��Rond Sliouider Area: All Construction Debris sha116e removcd frorn the job
sitc on a dAily bnsis. All stockpiled soil as wclt as ell o�her project materials that tvill be staged within the
Right-of Wuy must be dciinented with reflective signage or other means ta meet the minimum requirements
of the NYS DOT Consiruction SWndnrds.
� � . �
GENERAL CONDITIONS OF P�RMIT
APPLICATION/I'�RMIT FOR I�iIGHWAY EXCAVATI4N AND REPAIR
� (Contanucd) . ,
�p, Inst�11,Maintzin�rasion Cantrals: Reyuired Erosias►Contral Measures(i.e,silt fencing)is to be placed
on tfic downslope edge of t�ny disturbed area, This sediment barriec is ta be put in place before sny
disturbancc af thc ground occurs and is to be mnintuined in good functionaf conditian until thick vegetutive
cover is established. '
11. Clean Till Only: AII project back-rll sl�all consist of clean sand,gravel or soif(NOT asphelt,slag,flyash�
broken concrete o�'demolition debris}, All unsoitable soils cxcavAted at thc site{i.e.Clny�Bog,etc.)arc to
be removed from the sitc and nat used to backfill any excavatian within u Town Highwuy.
1 Z. A!I Areas of Soi�Dieturbunce: Ali aceas'of soil disturb�nce resulting from the approved project sl�all be ,
sta6ilized to the sutisfaction oFthe Highway Superintendent immedia�cly following project completion, If
thc project site rcmains in�ctive for more thsn 48 hours or plunting is icripractacal due to ihe season,tl�en
the area shalt be stabilizad with stiaw,hay muich and/or jute matting until weather conditions favor
germination.
�3, l3:ictcfill&Comnactinn at n1!�acs�v�tions: Back Fill shall consist of cicun f ll o�soils which exhibit a
� well=defined moisture density relationship as determined to be in uccordance with ASTMD 698. Fill,shal!
be placed in m�icimum lifts of tweive(12'�inches thick and shatl be meciianicully compacted tn a Ninety=
• fVe(95°/a)percent maximum dry density. Snitable hydi�iulic compaction by water jet#ing afthree-foot
intervals wilt uls6 be permit#ed subject to a project specific upproval by the Highway Superintendent,
14. Restorsition of tlic Ra��l Shoulder Area: A1)inan-madc improvcments located within existiwg road
shoulder ares�s must be protected to the greatest extent practical. ,Items would inclado but not be limited to
drivewAy 8i private road aprons,rriait boxes,sprinkler systems,tr$es and omamental piantings.
Excuvations through drivetvays tind private rond pavement�must be ceconstructed to meet all requiremenLs
of SouthoEd Town Highwey Specificntions. All pre-eXisting road shoulder improvements thst have been
disturbed duriqg construction must be replaced or repuired by the contracfar to the satisfaction ofthe
- Highway Superinlende'n� � " �
15. Scliemntic Piuns tiviil�nll Tecl�nicai information and Scone o!'�Vork: To reassonably nnd udequately
describe the pioposed work,�accuiute schematic site pians must be provided to shaw�or indicate'aU ,
- proposed canstruction activity required under,this permit. AI[Pavcme'nt surfaces saheduled for excavAtion ,
must be saw cut to the fvll depth of asphAlt and/or cancrete puyemenks. Accor�te size of Uell holes or width
'oftrenehing must be indicatod by`dicnension or labeling. This schematic site plan must piovide details an
all restoration required to meetthe rcquirements ofthcse Genera!'Conditions and requirements found in ihe
Sauthold Town Highway Specifications.
16. Psavement Recoustruation: All Pavement sections must be reconstructed in the foltowing msnner,
(Note:Whsn Concnte Pavemonts ere Present,Plcase revlew Rcstoration requircmcnts with the Highway Superintendenl)
a) Complete aU back-fill&�soif compactiori work�needed to provide A suitable sub-be'se;
b) Over-cui existiag ssphalt bell hole or trench by hvelvc(12"}inches on all sides;
c) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must mcet NYS DOT Specificatian); �
d} lnstatl u two und ane hulf(2.5'�inch compucted lift of Asphalt Dase Conrse;
c) lnstaU a one and one half(1.5")inch of Asphalt(Type 6)1Vearing Course. {Provide AC at all joints)
All work listed hcrein must meet the minimum requiremsnts of the SQuthold Town Highway
Specifications:
17, Trenchin�af Pnvcment Snrfi�ccs�xceedine Onc Ilundred(100'1 Tcct in Len�tl�: All trenching of
puvement surfaces exceedins 100' in length must first be ieconstructed to meet the requirements of Item
# 16 us noted abave. Once Ail pavement recanstntetion is complcied to the ssstisfaction of the Highway
Superintenderit,the entire rond section�nd/ar width of roacS ovcr tl�e ent'sre lengih oFVench shall be
repaved with cs two(2") inch iift of Asphalt{Type�Wenring Course(Typical,shQulder to shoulder).
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� . PERh+iTr�APFLICATI�IIT SKETCH-, i
-'�i llage Of= . ' , '
I?ATE: �����I�O�� . I�'
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LOC,iiTI(]�T:� 2�00 �fILLA�GE LN CR�SSSI'REET 1: V�IILL'ODU ST �
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TOWN: ORIENT GR4SS Sl'REET Z: .. . a.
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'4�0[tIC�ORDER: T'I O�������, � �
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* * * RECEIPT * * *
Date: 08/02/16 Receipt#: 211529 '
Quantity Transactions Reference Subtotal
1 Excavation Permits 1142 $170.00
Total Paid: $170.00 ,
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N otes: ;
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Payment Type Amount Paid By I
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CK#35471 $170.00 National, Grid -Gas Permits. i
Dept I
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 FI 1
Hicksville, NY 11801
Clerk ID: LYNDAR
Internai ID: 1142