HomeMy WebLinkAboutOaklawn Ave (3) Permit No. �`I
TOWN OF,SOUTHOLD ��suFFOtkco
HIGHWAY DEPARTMENT
Peconic Lane 94
Peconic,New York 11958 c
(631)765-3140
APPLICATION/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,atid'other applicable laws,ordinances or
'regulations for each.individual contiguous excavation project herein'describe'd. 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 permit authorized
inspectors to make necessary inspections of the job site.
PrintorT,lc Keyspan Gas East Corp D/B/A National Grid
Gas Permits Dept, Bldg: 3 FI: 1
l 175 E. Old Country Rd Hicksville, NY 11801
Name of Applicant Phone Number Address of Applicant-
2.
Name of Contractor Phone Number Address of Contractor
3. lel 8I
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. AvA iqwp ME-- 2�� d AA 6/,9 low J& PP4 5,9 1/Tff
Work'Descriptionand Location(Street Number,Hamlet,Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes,other Town permits may be required.
Lw—ltp� 61
NOTE: All information requested by this S nature of Appli nt
Application/Permit Form is (0z
�,/Required for a complete application! _I
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 , Section Block Lot
7. Starting Date: Completion Date:
8. Work Schedule: Phase Completion Datc
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:®�GIV `sC���l ' MW e-&T-1®Ay A7—J (S)S 3�{M V sS A)P ✓Lr ATg
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;Bell Hole and/or every road opening orexcavation 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. la /Service Connections excaations $20 00 '$ D,
o. �E�L HoL�S u��rn! d J�ADl�g
A2. /
0
B. Excavations 18"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 —
p,• � -oZ els
' TOTAL$
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:
accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if y)attached here
SUPERINTEND T W YS
TOWN OF SOU 1- RK
Vi cent .Orl
Date
Date Received by the TownJerk lJ
Date Permit Issued 613 ( PermitNo. l l I V
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 RECONS
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 Io 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
GENERAL CONWTIONS OF"-PERNIIT;
APPLICATION/PERMIT FORHIGHWAY EXCAVATION AND_REPAIR. ,
1. Permittae's Contractars'io Conitily�with-PermitReguiremenis: The Permittee is°responsible for
informing its independent contractors,°employees;agents•and assigns of their responsibility to comply with,,
mit
-this`per , including'all special/site .specific and general;;conditions imposed by the:Hi'ghway
Superiniendent'while acting as the,permittee'.s:age-nt with respect to the'-permitted•activities;-and such
persons'shall,be,required to comply with all permit requirements.'
2. No=Riuht'fo-Trespass�oe Infcrfere ivith Privsite Property'R ahfs:,This permit does;not,convey to the
permitted:anyrigh`t io trespass upon.the lands of.adjacent property ovvners in ordertoperform the.pe`rcr►itted.
work nor'does it authorize the'impairinerit of any'rights,title;•or,interest'in real or,personal property,held,or
vested-in-mperson not a party:to-the permit.
3-. Pr•oteciion of lh`, 11 nyay And Future-l'Tii!liwayt'MaintenAnce:,,If-future operations or highway
maintenance-piojects`.by,the Town°of Southold'"require an alteration•-in the•position of the utility;atructure
,or work'herain authorized,°or,if,'in the opinion of the Highway Superintendent the work performe'd,under
this permit shall cause•unreasonable obstruction to required,highway',maintenance,or endange'r,=the health,
safeN;and/or welfare of;vehicular or pedestriari,tr`affic,this permit shall be revoked and the utility,
structure,f ll,;excavation;'or other modification,of the-highway hereby,abthorii6d shall not be completed.
Additionally;the permit may be reyoked.if ihe,Highway Superintendent finds tha the issuance of,tlie
permit wa's`illegal or.unauthorized or thafthe applicant failed to complywitli any.of the terms and
conditions of the,perniitor Chapter 237 of the Townl-Code.
4. ,Revocation of tiiePemiit liy,thc'TIiahFyay Suneiintenilent: If the Highway Superintendent deems Lit
necei"iy,to revoke•this permit and the project-hereby awho- ized:has,not been completed,the;applicant
shall';without expense to the-Town andto 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 restorethe site to its
former,condition.
5. -Notice of•Commencement:;At-least hours.prior to commencement of the project,the permittee and/or
contractor shall'notify;the,Town Highway Departmenfin,wiitirig that they are fully aware,of and
understand 611 terms and'project conditions of this permit. Upon completion;of the'work;the contractor
shall provide ph&ographs'of the completed work�to the Town Highway Department and request'a Final
inspection.
6: Stoih a o'f Equipment&'Materials: The storage of construction equ;ipmentand/or mAteriI I shall be
confined within the-project work area and/or'adjacent areas where permission/legal access has,been
obtained in-a manner thatd' not°interfere with normal,highway traffic.
7. 'UtiliiyaMarli-Outs:-The Applicant/-Contractor shall,be responsible for`verification,of all existing utility
mark=outsrand shall take all precautions to.protect"`same, .Damage to existing utilities shall'be the, .
responsibility'of the•contractoi and shall be repaired;at,the contractor's expense.
8. Road.Closures: All scheduled road closures must first receive written permission from the SoutholdTown
Board•prior.to`closing a road. Temporary lane closures maybe permitted with the approval of the Highway
Superintendent., This item will included but not`be-limitW'to the installation-of Appropriate signage and
flag mento" ' andstarttraffic,to•allow for single lane traffic.:Road Closures'due•to unforeseen
emergencies-require'imme.diate.notif cation ofthe Highway Department-and shall be limited to'immediate
and/or expedited restoration the Work.Zone,
9. No Construction.Debris in Road Shoulder•A:rea:.All Construction Debris shall be removed from the job
site on a`daily,basis,.-All stock'pil_ed-soil.as well as.a11`other°project materials that•wiil 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'Constriuction Standards.
�',.GENERAL.CONDITIONS-OF PERMIT;,'
APPLICATION/PERIVIITY 'EXCAVATION AND REPAIR•
(Coritiiiued) ;
I a._'jnstxll;Mairitain.Erosion.Controls:,,Requiied Erosion Control Measures(i:e.silffencing) is to be placed
on"the downslope'edge of ariy,disturbed area. 'This,sediment'barrier'is to be put,in place;before any
disturbance of the ground occurs and is to be maintained in go od.functional,condition until thick vegetative
cover is established:,
l l.;.CleRn.Fill-Only:.Allproject'back-fill shall consistof'clean sand,,gravel orsoil(NOT'asphalt,slag,flyash,'
''broken',concrete or'demolition'debris).''All unsuitable soils,ekcavated'at thel'site(i.e.-
Clay,B'og;`eta.)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
stabilized1dihe satisfaction of the Highway.Superintendenf imtnediately'following projertcompletion. If
the.projdct siie'r6ma'ins'itiactive'for more than'4064s-or7plantinIg is'imp ractical due to.the'season,,then
the area_hall be stabilized with straw,hay,mulch and/or jute-matting until weatherconditions favor
germination. `
13.'I3nckfill''&Corapaetion bf h1l Excaivations:. Back Fill sliall consist of clean fill-or soils which exhibit a
well'-'defined moisture density'relationship as-determined tube in`accordance with=ASTMD 698. Fill shall
be..'placed in.maximum,lifts of twelve(12")inches,thick and shall-be'm'eclianicahy compacted to a:Nin@ty-
five`(95%)per`centmaximum dry density. :Suitable'hydraulic,coiiipaction:by water jetting at three-foot
intervals wilt also betpermitted subject to a project specif d,a,pprova]'by,,the Highway Superintendent.
e
14.•Restbrafiofi, � .theRoad",Slioalder'Arcat:,All man=inade.improvements located within existing road,
shoulder areas x`nust,be protected to the greatest extent,practical.-Items would include but:not be limited.to
driveway&private'road aprons,mail boxes,'spririkier systems,trees and ornamental plantings:;
Ekcavations`through driveways and privato road pavements must,be reconstructed to,meet all requirements
of Southold Town'-Hig11
h'way Specifications; All pre=existing'road shoulder,improvem'ents that have'been
di'sturbed.during construction must be replaced or repaired by the contractor,to the`sati faction of the
Highwayrsuperintendent.
•j 5. rvith>all Teclinicsihinformation'ti[nd Scone o`f Worli' To•reasonably and adequately
;.
describe the proposed work,accurate schetmtic site plans'must be provtded,to show,`or iridicate'all
proposed`construction activity required under this permit.,'All Pavement surfaces;scheduled for excavation
must be saw cutao the;full depth o£asphalt atid/or_concreie pavements.,Accurate size of bell holes or width
of trenching must b'e,indicated'by dimension or;labeling. This schematic site "la must,provide details on
all restoration required to'm' eet the requirements•ofthese General Conditions'arid requirerrients found in the
Southold,Town,Highway-Specifications.
16. Pavement Reconstruction:`All Pavement sections must'be reconstructed in the following-mariner;
(Note:,When'Concrete Pavements'are Present;Please review RestoritionsegWrements with the Highway Superintendent)
a) Complete all back-fill,&soil compac'tion'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 compacied�lift uf•4"thick Stone Blend base(RCA Blend must;meet
d)' InstalNYS DOT Specification);
I a two and,one half(2.5')inch compacted lifttof Asphalt.Base'Course;
e) Installa 6tid aitd'one half(1.5")inch of Asphalt(Type 6)Wearing Course: (Provide AC at all joints)
All work listed1crein must meet the`minimuin"requirements of the Southold Town Highway
Specif cations.
17. TreneliinlrofPavement Surfaces Exceeding 0ii6nunilrcd"(100'-1Teet--iiiLenatli:,All trenching of
pavenierit'surfaces,exceeding 100' in',length must fh t.be reconstructed to meet,the requirements of Item
# 16 as noted above. Once all'pavement reconstruction is completed to'the,satisfaction;of the Highway
Siip'eriritendent,the entire road section arid%or width of road'over the entire length of trench'shall be
repay' d v"ith'a'two(2"} inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder-to'shoulder).
sj iy
Oaklawn Ave (Main Road to Jernick Lane) natonalgrod
Southold
Road Opening Summary - T101876529
3x3 Bell Holes (7) = 63 Sq Ft
5x3 Send/Receive Pit (3)= 45 Sq Ft
5x8 Connection Pit (2)= 40 Sq Ft
Total Square Footage= 148 Sq Ft '
Total Drill Linear Footage= 1350 Ln Ft
Engineer: James Perry
Contact: (347) 838-0354
CL
8x5 5x3 5x3 5x3 8x5
1320'
Oaklawn Ave �iCT
CL CL �
C
Key
(All Typical,Not to Scale)
® Soil Excavation
® Roadway Asphalt Excavation
---- Horizontal Directional Drill
Trench Line
* * * RECEIPT * * *
Date: 08/31/16 Receipt#: 212908
Quantity Transactions Reference Subtotal
1 Excavation Permits 1148 $990.00
Total Paid: $99000
Notes:
Payment Type Amount Paid By
CK#35716 35670 $990.00 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
Bid 3 FI 1
Hicksville, NY 11801
Clerk ID: BONNIED Internal ID: 1148