HomeMy WebLinkAbout1000 Marlene Ln Permit No.
HIGHWAY D PA TM NTUTHOLDSUFfO�,t�4Gy
Pecotiic Lane:
Peconic,New York 11958 a
(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,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,-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 I ac Keyspan Gas East Corp D/B/A National-Grid
Gas Permits Dept, Bldg:.3 FI: 1
1 175 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.
Name of JProperty Owner Requesting Service((iifapplicable) Address of Owner
Work Description and 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.
NOTE: All information requested by this Sign ture of p scant
Application/Permit Form-is
9 P PP p- �� &
Required for a complete application! O !!!
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�J7. Starting Date: qW11 Completion Date: 7 M 71/t0
8. Work Schedule: Phase Completion Date
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
roJ '
posed Work: c/ $ 'I' •,�.� j� j r,} /y�
11. Remarks: O �G AI) I' , J I
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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 or excavation 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. /Service Connections excavations @$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. 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 / �f
TOTAL$ 1 lig
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:
kinaccordaJoreto
this application and subject to the"General Conditions"and"Special Conditions"of attacheSUPERITOWN
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Date Received by the Tow Cler Date f b f
Date Permit Issued Permit No.
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)
INSPECT®R'S"RECORDS
Inspection Date Findings(use code) Applicant Notified
1St
2nd
3rd
4th
(To Permit`Clerk)
REMARKS
' 1
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
GENERAL CONDITIONS OF PERMIT
APPLICATION%PERMITTOR HIGHWAY)EXCAVATION AND REPAIR',
1. Permittcc's Contractors fo Comply tiyiih=Pcrmit°Reguirem`eliis: The Permittee is responsible for,
informing its`iridependentcontractors,einployees;4agents andissigns'of their responsibility to'comply.with
this permit,including all 'speciaUsite specific.arid general'conditioris imposed by the,Highway,'
Su perintendent-while•acting as-tfie permittee's'agent with respect to the permitted activities;and such
persohs=shail be required to comply vtiwitli'all'perinit requirements.
2. 146 Rikht,to'Tres'Oass or Infcrfcrc W'itlf Private Pronerty'Riahis:,This permit does not convey to the,
permittee;any,right.to4respass upon the'lands of adjacent''-property oivners'in`order'to,perform'the permitted
work nor''doe's-it autliorize the'impairment'of any rights,title;.or interest in real or-personal property,held or
'vested°in,a,person,not a party to'the,permit.- ,
3. Prot cctian Ot ilic iiigliiV.V:and Filtul'@,Higliw4 y Maintenilnce:,.If future operation's or highway '
maintenance project`s'by the Town,of-,Southold`require'an,alteration in,the`position=of.the utility,structure
or work herein authorized,bmf,in the opinion of.the Highway Superintendent.the,work performed under
this pe'rinit.shall'cause unreasonable obstruction to required;highway maintenance or endanger the'health,
`safety and/orIwelfare ofvehicular'or pedestrian,traffic,this permitshallb,e revoked and the utility,
structure,fill,excavation;or.other modification of=the highway herebyauthorized shall not,be completed.
Additionally,the permit maybe�revoked_-if the Highway Superintendent finds thafthe issuance.of the
permit`was,lllegal'or.unauthorized ortllat'the'applicant failed to comply with any of the terms and
'conditions of the perrnit;or.Chapter.237 ofthe' wn Code.
bci4. R`e"vition,of thePerni t byllIle'Hiuhway S`uperintenilent: If,the Highway'Superintendent deems it
nece-sary,,to revoke,this permit and the project°hereby authorized has'hot,been completed;the'applicant
shall,.without'expense to the•-Town'and'to such'extent and.in suoh'time and manner,asthe Superintendent
may require,{remove all or any portion of the uncompieted'utility,'structure or,fill,and restore the site to its
former condition.` v
5. Notice of Commenceliient: At-least 24.hours,prior to-coinmencernent of,the project;the permittee and/or
contractor shall'notify-the,Town Highway Department in writing that'they are frilly aware,of and'
understand`allterms`and project conditions of this permit. Upon'completion ofthe work,the contractor
shall provide pho`tographs'of the completed work#o the Town Highway Department and request a Final
inspection.
6. Stor'ake 6f 4uioment&•-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 tliat'does not interfere with normal`highway traffic.
7. 'UtilitY.Mark-Out`s: T.he'Applicaat/Contractor shall be responsible for verification of all existing utility
mark=outs,and shall iake;all,p're'eautions to,protect'Isame. Dam'age.to existing utilities`shall,be the
responsibility of the contractorandFshalI 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.closirig a'road. Ternporary,lane closures may bepermitted with the approval of,the Highway
Superintendent. This item.will included but not belimited to,the,installation of appropriate,sigriage and
Mg men t ,o:stop and start-traffic to allow for single lane traffic.'•Road Closures due to unforeseen
emergencies require immediate not cation ofthe Highway Department and shall be limited to immediate
and/or expedited restoration ofthe-Work Zone, ;
9. No.Constructioxi-lDebiis in'RoAd Shoulder Ar`ea: All Construction Debris shall be removed fr6m the job
site on a,daily basis. All stockpiledsoil aswell as ail other project materials that will be staged within the'
Right-of Way•must•be delineated with"reflective signage or other means to me et the.minimum requirements
of the NYS DOT Construction Standards._
GENERAL CONDITIONS OF.PERMIT
A.PPLICATION/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 formore than 48 hour's 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. Backfill &-Compaction 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%)percent maximum dry density. Suitable hydraulic compaction by water jetting at three-foot
intervals will also be permitted subject to a project specific approval by the Highway Superintendent.
14.•Resto ition'of thc•Ro:td Shonider•Area:-All man-made improvements located within existing road
shoulder areasmust 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.
Excavatiops'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 oe repaired by the contractor to the satisfaction of the
Highway Superintendent.
15—Sehematic-11ans with all Technical-information and Scone of-Work:- To reasonably and adequately
descr'ibe:the'.proposed work,accurate schematic site plans mu' 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,
e 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.
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-fill'&s_oil 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 requirements of the Southold Town Highway
Specifications.
17. TrenehiriZ of Pavement Surfaces Exceeding One Hundred (100')I+cet in Length: All trenching of
pavement,surfaces exceeding,100' in length must first bereconstructed 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).
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MRWr "MICATION SKETCH 00
Village Of
DATE. 812612016
LOCATICN: 1000 MARLENE DR CROSS STREET 1: MAIN RD
TOWN: MATTITUCK CROSS STREET 2: PECONIC BAY BLVD
l�ORK ORDER: T101877871 I
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SURFACE:
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1000
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1266'
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4' x 4' Bell Hole
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MARLENE DR
4-03
* * * RECEIPT * * *
Date: 08/31/16 Receipt#: 212913
Quantity Transactions Reference Subtotal
1 Excavation Permits 1150 $17000
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#35741 $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
Bid 3 FI 1
Hicksville, NY 11801
1
Clerk ID: BONNIED Internal ID: 1150