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Home My WebLink About8100 Indian Neck Ln r ' ` -, Permit No. � TOWN OE SOUTHOLD . yQs�F��1��, HIGHWAY bEPARTMENT ��° °�� Peconic Lane � � �Peconic,New York�l 1958 =�� s � (631)765-3140 y�ipl,r� ��o� APPLICATION/.PERMIT FOR HIGHWAY EX�CAVATION AND REPATR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Soutl�old for tfie issuance of anExcavation Permit pursuant to Chapter 237 of the Code of the Town of Sovthold,Suffolk Count}�,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,'tlie atCached"General Conditions of PermiY'and"Special Conditions",if any and to permit authorized inspectors to make necessary inspections of the job site. Print or Tvpe 1. ' Name of Applicant Phone Numuer Address of Appticant 2. "�� C� t�e�� . �$� L i �, ��c��l � ;`� �91 y� Name of Contractor P one Number Address of Contractor 3. . ' O �� 4� �� _(�e � c _ �o�e L�re �e cu� O Name of Property Owner Requesting�Service(i applicable) Address of Owner 4. ��p�C i� �iYIGC�� '�t"1 4J' ' Work Description and� ocation(Street Number,Hamlet,Cross Street) X (a) Is construction Iocated within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. � NOTE: All information requested by this Signature of Applicant Application/Per•mit Form is Required for a complete application! � �S �� Date 5. (a) Attached plot plan to reasonably and adeqaately describe the'proposed work. Provide accurate scherriatic site p]an 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]icenses for this project: (c) Work covered by this application may riot corrmmence before issuance of a Highway Excavation,Permit by the Town Clerk, 6. Tax Map No.: District 1000 , Section , Block , L-ot � 7. Startillg Date: Compietion Date: � 8. Work Schedule: Phase Comnletion Date ` Excavation Work Schedule , Facility Installation NYust be provided BackfiIl&Completion for consideration as a Pavement Replacement Gomplete Application. 9. Under which authority is application bein�made: See Tovvn Code ChapteY�37(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estiinated Cost ofProposed Work: $ �i �O • 11. Remarks: �`� �,-�.�t �.-��t� �- �L�- ��u E /2�i�'a v,�f-�, Ql�C!5Ls C� . D-39 � 1 of 3 � . � 12. ]nsurance Coverage:(Attach Copy) (a)� Insurance Compaay: ��S �i� �� (b) Policy#f: (c)State whether policy of certif cation on file with the Highway Deparhnen� (d)Coverage required extended to the Totivn: Any I.oss including Bodiiy injury,property or commercial injury caused by or attributable to the work performed: $I,q00,000 per Occurrence and�2,OOQ000 general a�,°regate. 13,. Secvrity; ,1- �, � (a)Surety Bond ��`��n or Certified ChecK provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Appiications and perinits: '� Basic Application Fee for Each P�oject Location - $150.00 , A ProJeet Location would�inelude eaeh Bell Hole andTor every road opening or excavation within an}� 50'Radius"whether=or not they may be inter-conaected tiy open trench or directional boring. The total number of Project Locations shall�be subject to the approval'of the Highway Superintendent. AI. � /Serlic�Gonne�tions excavations @�20:00 � �v . �o � No. _ A2. . 1 Additional Excavations same-service a $10.00 $ No. B. �Excavations 18"in depth or less / . 0-100 L.F.=$10.00;Additional /�`� L.F.@.$0.10 $ /(G� UD C. �ccavations 18"in depth.to 5' in depth 0-100 L.F._$30:Q0;Additional L.F.@$0.30 $ D. Exca.vations 5'in depth and over 0-100 L.F.=$50.00;Additianal L.F_@$0.50 � E. � UtiliLy Repair Excavations @�I0.00 � No. Repairs same sarvice @$5.00 $ Additional ` 1 TO'I'AL� ! �� ` U� _ F. Natice io gu'ulic-utilities p;oafr„�st�e praY;�ed a;,d Shall be attached to this application prior to issuance of pernnit. ,� � �= �: * � x� � � � �, � * * Authorization is hereby granted to the Town Clerk of.the Town of Southold ta issue a Hightivay Excavation permit to: in accordance with this application and�snbject to the"General Conditions"and"Special Con'ditions"of pe t(if any)attache here .. � SUP 'H YS - TOWN_ S EVI� OTtK (nceri��i�'laryd� � ��/ � ��l/ Date Date R�ceived by.the Town Cierk �� Date Permit Issued �� d� �� Pertnit No. � �� NOTE: Permit expires one(1)year from date of issuance. Na work to.start wi�hout 24 hour nvtice to Superintendent of Highways, P�rmit must be available at all fimes for inspection,on sita,duririg�construcfion. D-39 -- 2 of 3 Copy Disiribution: Permit# Highway Departinent .Engineer`(with page 3) Applicant . Town Cleilc(Original) II�i�PECTOR'S.RECORDS Inspection Date •Findings(use code) Applicant Notified l sf � 2nd 3rd 4a, _ (To Permit Clerk) REMARI{S CODE IB Improper Barricades IL Improper Lights- ST Sunken Trench or Excavation UTM Unable to Meas�re(duetto�back�lling) BUC Building Under Construction WIP Work In Progress DB Improper Backfill(too lugh,not suff cient) HFS Inspector Holding for FinaI Settlement of Excavation RFR Ready'for Repair D-39 3 of 3 � �� - l y,owa� a,,1 �e� �o�s�� ; �'1 _ �� z , �r,o� v�� } o .��,«� �� L � ' � � v� ' J 9 J r Q ,[� 03 � ' L2� � �ti �z'� / _ ,,��,,� � � � � � � . > �� J d �� / �� V� � t rv ' , GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Permittee's Contractors to Comply with Permit Requirements:_ The Permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all speciaUsite 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 Ri�ht to Trespass or Interfere with Private Properiy Ri�hts: This permit does not convey to the permittee any right to trespass upon the 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 properiy held or vested in a person not a parly to the permit. 3. Protection of the Highwav and Future Hi�hwav Maintenance: 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 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,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 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 of the Permit bv the Highway Superintendent:_If the Highway Superintendent deems it necessary 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 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 Commencement: 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 permit. 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,.ge of Equinment&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 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 tra�c. Road Closures due to unforeseen emergencies require immediate notification of the Highway Deparhnent and shall be limited to immediate and/or expedited restoration of the Work Zone. 9. No Construction Debris in Road 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 must be delineated with reflective signage or other means to meetthe minimum requirements of the NYS DOT Construction Standards. i � � '' , � , 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 fayor germination. 13. Backfill& Comnaction of all 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 thick and shall be mechanically compacted to a Ninety- five(95°/a)percent ma�cimum dry densiiy. Suitable hydraulic compaction by water jetting at three-foot intervals will also be permitted subject to a pr.oject speci�c approval by the Highway Superintendent. 14. Restoration of the Road Shoulder Area: All man-made improvements located 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 and ornamental plantings. 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 that have 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 Scoue 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 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 meet the requirements of these General Conditions and requirements found in the Southold Town Highway Specifications. l 6. 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 sub-base; b) Over-cut existing asphalt bell 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 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 requiranents of the Southold Town Highway Specifications. 17. Trenching of Pavement Surfaces Exceedin�One Hundred (100')Feet in Len�th: 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). s�,y * * * RECEIPT * * * Date: 08/25/16 Receipt#: 212693 � Quantity Transactions Reference Subtotal 1 Excavation Permits 1145 $180.00 Total Paid: $180.00 Notes: Payment Type Amount Paid By CK#5661 $180.00 R & R, Construction Southold Town Clerk's Office � 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: R & R, Construction 282 Line Rd Manorville, NY 11949 Clerk ID: BONNIED Internal ID• 1145