HomeMy WebLinkAbout700 Peconic Bay Blvd -- -�` -- - - - -- - i - - - - -
L�Permit No. '
� TOWN OF 50U�TOLD T ����SUFFO�;��
HIGHWAY DEP ,�
Peconic Lane ,��: z�i
Peconic,New Yorlc 1�1958 `�a� �,, �
(631)765-3140 ' y��� ,� ,��a�
APPLICATION/PERMIT FOR HI(�HWAY�XCAVATiON AND RFPAiR
APPLICATION IS HEREBY�made to tlte Superintendent of Highways of the 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,a►id other applicaUle laws,ordinances or'
regulations for each individua]contiguous excavation project herein described. The applicant agrees to co'mply 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 Tv�e ' Keyspan Gas�East Corp D/B/A National Grid
Gas Permits Dept, Bidg: 3 FI: 1
� � 175 E, Old�C�untry Rd Hick�ville, IVY 11801
Name of Applicant Phone NumUer Address of Applicant,
2. J / ���/��v`�
Name of Contractor Phone Number Address of Contractor
3.
Name of P operty Owner Requesting Service(if app icable) Address of Owner
4.
�� ����li� � ��.��.5��5 , G��- L�'7 ' �IO ���� � N
Work Description and Location(Street Nurnber,Hamlet,Cross Street)
(a) Is construction located wit}iin 75 feet of tidal�vetlands? *Yes No
*If yes,other Town permits may be required. �� n ,
%�
NOTE: All information requested by fhis Signj�ture of pplicant
Application/Permit Form is �// .�. /�b
Required for a complete application! �
Date
5. (a) Attached plot plan to reasonably 1nd adequately dascribe 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�vork,
(b) Attach all other necessary permits and licenses for this project.
(c) Work covered by iltis application may not commence before issuance of�Hi�hway Excavation Permit by the Town Glerk.
6. Tax Map No.: District 1000 , Section , Blocic , Lot
7. Starting Date: Completion Date:
8. Work Schedule: Phnse Co►nnlction Dnlc
Excavation Work Scl�edule
- Facility Installation Mitst be provided
Bacicfill&Completion for consideration as n
Pavement Replacement Compiete Application.
9. Under which authority is application being made:
See Town Code Chapter 237(E)-Provide Reso]ution by,or authority from,the Utility beitlg modified.
10. Estimated Cost of Proposed Work: $
11. Remarks: ���N �� � � `��'` � �bl�Il�i�� �T6�/Ll�'� ��J �f�/w�� �
°�6�0 �"CDP�It� ,a� �r-`� __
D-39 ` 1 of 3
/
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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,properiy or commercial�injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and�2,000,000 general aggregate.
13. Security: ' �
(a)Surety Bond or Certifted Check provided in the total Amount of$
� (b)Maintenance Bond provided: � 2 years or 3 years.
14. Fees for Applicafions and permits:
Basic Application Fee for Each Project Location - $150.00
A Project Location tivould 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.
Tbe total number of Project Locations shall be subject to the approval of the Highway Superintendent.
A1. O� /Service Connections excavations cr $20.00 $ �� ' �
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. Eiccavations 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 g.�
' TOTAL$ ` ��r � v
F. Notice to public utilities proof must be provided and
Shall be atfached to this application prior to issuance oFpermit.
* * * � * * * * � * * * * *
Authorization is I�ereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
' in accordance ith
this application and subject to the"General Conditions"and"Special Conditions"of permit f any)attached h to.
SUPERINT T A
TOWN OF , YO K
� Or�c�
��
S f�6 Date
Date Received by the Town Clerk �
Date Permit Issued � �� �� Permit No. �"t (
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 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)
- YNSPEC'TOR'S�CORDS
Inspection Date Findings(use code) Applicant Notified
lsr
2nd
3 rd
�th _
(To Permit Clerk}
. RElYIARKS '
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
r � �
. GENERAL CONDITIONS�OI{'PERMT7C
' APPLICATION/I'ERMIZ'FOR HIGI�WAY 3CXCAVA'TION AND 12�PAIR
1. Pcrmittcc's Co�itraciars`to Complv tivith Pcrmit Requiremenis:_ The Permittee is responsible for
inform'ing its independent 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 permittee's agerit with respect to the permitted activities,and such
persons shall be required to comply with all permii requirements.
2. No'Ri�l�t io Tresn�ss or Interferc�witt�Priv�te Pronertv`Ri�hts:, This perntit does not convey to the
permittee any�right to trespass upon the lands�of adjacent prbperty owners in order to perform the permitted
work nor does it authorize the impairment of any rights,�title,or interest in real or personal properiy held or
- vested in a person not a pariy to the permit.
3. Proieciian oTllic Iii�t��vav:�nd Tuiure IIi�liws►v'Maintenanec: If future operations or highway
maintenance projects by the Town of Southold requiie an alteration in the position of the utility,structure
or work herein authorized,or if,in the opinion`of the Highway Superin'tendent the,work performed under
� this permit shall cause unreasonable obsiruction to required,highway maintenance or endanger the health,
safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the uti]'ity,
structure,f lt, excavation,or other modification of the highway hereby authorized shall not be completed.
Additionally,the permit may be revoked if the Highway Superiritendent 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 tha Town Code,
4. Revocation of ihe Permit l�v the IIi�hwav Sunerintenilent: If the Highway Superintendent deems it
nece'ssary to revoke this permit and the project hereby atithorized has not been completed,the applicant
5ha11,without 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 Uncompieted utility,siructure or fill and restore the site to its
former condition.
5. Notice of Commenceinenh �At least 24 hours prior to commencement of the project,the permittee and/or
contractor shall notify the Town Highway Department in writing that they are fully aware of and
understand all�terms'and project conditions of this pennit: Upon eompletion of the work,the contraetor
sliall provide photographs of the completed work to the Town Highway Department and request a FinaI
inspection.
6. Stora�e of rquipment&�M�tcrinls: 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.
�, Utilitv Mark-Oufs: The Applicant/Contractor shall be responsible for verification of all existing utiiity
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 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 Clo'svres 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 Construction Debris in Ro7d Slic�ulder 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 must be delineated with reflective signage or other means to meet the minimum requirements
of the NYS DOT Construction Standards.
�
A � . -
" GENERAIL CO1o1DITIONS OF PERMIT
APPLICATION/PERMIT�OR I-�IGI�[WAY EXCAVA�'ION ANA REPAI92
(Continued)
10. �nstall,lYXaintliri�rosion Cont'rols: 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 untiI thick vegetative
cover is established.
1 l. Clean�'ilLOnl��: All project baek-fl]shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash,
broken conerete or'demolition debris). All unsuitable soils excavated at the site(i.e. Clay, Bog,ete.)are to
� be removed from the site and not used to back�ll any excavation within a�Town Highway.
]2. A(I Arens of Soil DisturUance: All areas of soil disturbance resulting from tha'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.I3ackfill�&`Campact'ion 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 aocordance with ASTMD 698. FiII shall
be placed in rriaximum lifts of rivelve(12")inches thick and shall be meclianically compacted to a Ninety-
� five(95%0)percent maximum dry clensiiy.' Suitatile hydraulic compaction by�water jetting at three-foot
intervals will.also be permitted subject to a project specific approval by the Highway Superintendent.
14. IZestoration of tl�c Road Sl�oulder Area: All man-made improvements�located within existing road
shoa(der 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 and'ornamental plantings.
Excavations ttirough driveways and private road pavements must be reconstructed�to meet all requirements
of Southold Town Highway Specifications, Al] pre-existing road shoulder improvements that have been
disturbecl during construction must be replaced or repaired by the contractor to the satisfaction of the
Highway Superinteni3ent,
15. Scl�e�i�atic Plans rvitIi �I]Teclsnical informntion nnd Scone of'Work: ,To reasonably and adequately
describe the proposed work,accurate schematic site plans must be provided to show or ir►dicate all'
proposed construction activity required under this 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 requirements found in the
Southold Town Highway Specifications.
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-fil(&soil compaction work as'needed to provide a suitable sub-base;
b) Over-cut existing asphalt bel] hole or trench 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 lialf(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. Trenchin�of P�vemeni Surf.tces Fxceedin�O�te]=Iundred (100'1 Feei in 7Len�tlb: All trenching of
pavement surfaces exceeding 100' in tength 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]ength of trench shall be
repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course�(Typical,shoulder to shoulder).
s���
Road Operoing Perrnit Request nationalgric!
rHEaowEnoFncnoN
Munici alit : r Work Order: �� �
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Location: Grid:
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Town: / Requested By: , �'
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Reason For Excavation: -� /' �'� �^
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Description: � 'S����3'.B�LLf_jD�.t Dr1l_Tf/�f�JL/t�!�i�L/�1 l�fE_F�Vf.cf�.LrL1��p��'aX
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Typical bell hole excavation is 4'x 4'x 4' Revision:
Permit sketch may not include excavations required under 16 NYCRR Part 753 Date Submitted: E i5 /G
* * * RECEIPT * * *
Date: 08/25/16 Receipt#: 212692
Quantity Transactions Reference Subtotal
1 Excavation Permits 1144 $190.00
Total Paid: $190.00
Notes:
Payment Type Amount Paid By
CK#35644 $190.00 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: BONNIED Internal ID� 1144