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Home My WebLink About775 Skunk Ln * * * RECEIPT * * * Date: 08/19/16 Receipt#: 212429 Quantity Transactions Reference Subtotal 1 � Excavation Permits 1143 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#35623 $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 FI 1 Hicksville, NY 11801 Clerk ID: LYNDAR Internal ID. 1143 Permit No. RECEIVE[) TOWN OF SOUT'HOLD ��,qsuFFQt�',Co HIGHWAY,DEPARTMENT �,�� • �� u� � s 2o�s Pecoriic Lane ��', `� Peconic,New Yorlc 11958 p v- �, �� (631)765-3140 S�uthold Town Cterk ��rd�,�_,�yo� ` APPLICATION/PERMiT FOR HIGHWAY�XCAVATiON AND RrPA7R . APPLICATION IS HEREBY'made to the Superintendent of Highways ofthe Town of Soutliold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Coda of the Town of Southold,Suffolk County,New York,�and other app]icaUle 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�ermit authorized inspectors to make necessary inspections of the job site. Print or'['ypc Keyspan Gas East Corp D/B/A National Grid Gas Permits Dept. Bidg: 3 FI: 1 � � 175-E. Old Country Rd Hicksville, NY 11801 Name of Applicant Phone NumUer Address of Applicant 2. ' Name of Contractor Plione Number Address of Contractor 3. ��/�/ �� Name of Property O�vner Reqnesting Service(if applicable) Address of Owner` 4. 7�'� ��v�� .� -�g �9a'Sla �1�,v �-d Work Descriptiori and Location(Street umber,Hamlet,Cross Streat) (a) Is construction located within,75 feet of tidal�i�etlands? *Yes No *If yes,other To�vn permits may be required. , � . NOTE: All information requested by this ignature of Appl' nt � Application/Permit I+orm is �,` /, Required for a complete application: �� b Date 5. (a)'Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan sl�owing 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 ihis application may not commence before issuance of 1 Highway Excavation Permit by the Town Glerk. 6. Tax Map No: District 100 , Section `� , Blocic L , Lot � 7. Startin Date: � �� 4I� CompletionDate: / /�� S 8. Work Schedule: Phase Comnletion llnlc Excavation Work Scliedule Facility Installation Must be p'rovided Bacicfill&Completion for eonsicleration�s a Pavement Replacement Complete Application. 9. Under�vhich 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 Vl'ork: $ �J ,/ '/ � ��A �Q �(,� I � l 1. Remarks: � �!" � �� '1' `�`� //V�� U��L 1'� L� ____ D-39 , � 1 of 3 12. Insurance Coverage;(Attacli 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$2;00�,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (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 tivould i�iclude each Bell Hole and/or every road opening or excavation within any " 50'Radius whetfier or not they may be inter-corinected by open trench or directional boring. ' The total number�f Project Locations shall be subject to the approval of the Highway�Superintendent. A1. ^�/Service Connections excavations �r $20.00 � v`-'� ' � No. , A2. /Additional Excavations same service @$10.00 $ No. B. Excavations 18"in depth or less � 0-]00 L.F._$10.00;Additional L.F. a $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 RepairExcavations @$10.00 $ No. Repairs same service @$5.00 , $ Additional TO'�AL$ �/ � ' � F. Notice to public utilities proof must be provided and ' Sliall be attached to this application prior to issuance of permit. �x * � * * * * � * * * * * * Authorization is l�ereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: i ccordance 'h this application and subject to the�"General Conditions"and"Special Conditions"of permit(i a attac d r to. SUPERINTE AY TOWN OF S L , YO Vincent ,Or � / _ Date ' Date Received by the Town Clerk �— � ��.P Date Permit Issued ��1"( �� PermitNo. ( � �J NOTE: Permit expires one(1)year fi•om date of issuance. No work to start without 24 hour notice to Superintendent of Highways. Permit must be availaUle at all times for inspection,on site,during construction. D-39 2 of 3 Copy Distribution: ' u , Permit# � �'—I��._ , Highway Department. Engiiieer(with page 3) Applicant . Town Clerk(Original) YNSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified ' lsr , 2nd � 3 rd , 4tn, (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 Excavarion RFR Ready for Repair �D-39 3 of 3 r . . GENERAL CONDITIONS OF PEI2MIT APPLICATION/PERIVIIT FOIt HIGI�WAY EXCAVATION AN]D REI'AII� 1. Pcrmiti�c's Contractars io Complv�vith Pcrmii Requircments: The Permittee is responsible for informing its in�dependent contractors,employees, agents and assigns of their responsibility to comply with tHis permit, including all speciaUs'ite specific and general conditions imposed by the Highway Superintendent while acting as"the permiftee's agent with respect to'the permitted uctivities,and such persons shall be required to comply with all permit requirements. 2. No R'r�l�t'to Tresn�ss or Ynterferc wiil�Private Pronertv Iti�hts: This permit does not convey to the permittee any right to trespass upon the lands of adjacent properly owners in order to perform the permitted work nor'does it�authorize the impairment of any rights,title,or interest in real or personal prope'rty held or vested in a'person not a party to the permit. 3. Pr'oteciian of t1�cIlinh�v�v�nc#�+uture Iii�li�i�ay'MRintenancc;_,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 per►nit shall cause unreasonable obsiruction to required highway maintenance or endanger the heatth, 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 uriauthorized 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, 72e"vocation of li�e Permit tiv the IIi�hwav Sunerintenden[: If the Highway Superintendent deems it neeessary,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 suoh time and manner as the Superinterident may require,remove all or any portion of the uncompieted utility,structure or fill and res�ore the site to its former condition. 5. Notice of Carnmeneeinent: At least 24 hours prior to commencement of the project,the permittee andlor contcactor shall notify the Town Highway Department in writing that they are fully aware of and understand all.terms and project conditions of this penriit. 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. Stora�e of I�;quipment&N�s�terizls: The storage of consiruction equipment and/or materials shall be �corifined 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 tra�c. '7. Utilitv�Nd:�rlc-Ouis: 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 permitt`ed 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 trafftc to allow for single lane traffic. Road Closures due to unforesean emergencies require immediate notification of the Highway Department and shall be limited to irnmediate and/or expedited restoration of the Work Zone, 9, Na Construc4ion Debris in Ro�d Sl�ouldcr Arca: 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 reqiiirements of the NYS DOT Construction Standards, ' � - - " GENERAL CONDITIONS OF P�RMIT, APPLICATION/P]ERMIT�FOR I-�IGIEIWAY EXCAVA7CION AIVD 1�PAIR (Continued) 10. Install;�Mainiain�rnsion_Gontrals;_,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 distur6ance of the ground occurs and is to be maintained in good functional condition untiI thick vegetative cover is established. , 11. :Cle�n Fill Ontv: 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 back�ll any excavation within a Town Highway. 12. Al1 Areas of Soil D'esturbance: 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 proje6t site remains inactiva for�more than 48 hours or planting is-irnpr'actical dae to the season,then the area shall be stabilized with sfiraw,hay mulch and/o'r jute matting unti]weather conditions favor germination. 13. I3aekr1l�&�,Gompaefion af nll�xeav�tions: 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 meclianically compacted to a Ninety- � five(95%0)percent maximum dry clerisity. Suitable liydraulic compaction by�water;jetting atthree-foot intervals will also be permitted subject to a project specific approval by'the Highway Superintendent. 14..Restorntion of tlie Road Sl�oulder Area: -All man-made improvements loca'ted 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 arid ornamental plantings. Excavations'through-driveways and p'rivate road pavements must be reconstructed to meet�all requirements of Southold Town Highway Specifications, All pre-existing road shoulder improvemerits that have been disturbed during coristruction must be replaced or repaired by the contractor to the satisfaction of the Highway Superintendent. 15. Scl�e�aiatic Plans�vith all Tecl�nicnl�i�tformation nnd Sconc of�Work: To reasonably and adequately describe the proposed work,accurate schematic site plans must be prov�ded to show or indicate all propose'd c`onstruction activity required under'tliis 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 meetthe requirements ofthese General Conditions and raquirements found in the Southold Town Highway Specifications. 16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner;� (Note:When Concretc Pavements are Present,Pleasc revier`v Restoration reyuirements with the Highway Superintendent} a) Complete all back-�lf&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) Instap 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. Trencl�in�of P�vemenfi Si�rf.tces�xceedin�O�te Tit�ndretl (100'1 Teei in Lenatli: All trenching of pavement surfaces'exceeding 100' in length must first be reconstructed to meet the requirements of Item # 16 as noted ab'ove. Once all pavement reconstruction is completed to the satisfaction of the Highway Supecintendent,the entire road section and/or width of road over the eniire length of trench shall be repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder). s��y � � � ° ��a�lc�n�.l �� N N a �RMTr APFLICATI�N SKET�H � �lillage Of � � � DATE: $��JI��'I� ` � LOCATIOd�I: �7� �KUNK LN CR4S5SfREET 1: f�IIAIN RD � Townt: CUT�HOGUE CROSSSfREET2: BAYAVE � � wa�c oxn�x: T101873189 � � � � � � �r sct�rr,G�: � tt�aca��m Ro d� �,�rra � � � 77� � i?� � m A .� � � � �• � � � � on � 792' � b . � �4'��€4' Bell Hole � U .�. N � N �KUNK LN � � 3 � Q, � � . � Q. . - �