HomeMy WebLinkAbout1375 Ackerly Pond Ln Permit No.
TOWN OF SOUTHOLD �gt1FF0t��
HIGHWAY DEPARTMENT � V
Peeonic Lane
Peconic,New York 11958 0 '
T101884423 (631)765-31404
APPLICATION/PERMIT FOR HIGITWAY 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 orthe 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 PermiP'and"Special Conditions",if any and to permit authorized
inspectors to make necessary inspections of the job'site.
Print or 1h Keyspan Gas East Corp D/B/A National Grid
Gas Permits Dept. Bldg: 3 Fl: 1
l 516 545 4094 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 Property Owner Requesting Service(if applicable) Address of Owner
4. 1375 ACKERLY POND LN-W/S, 1157' W/O LOWER RD
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. i
Margaret Paglia
NOTE: All information requested by this Signature of Appi ant
Application/Permit form Is
Required for a complete application: 9/19/16
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.
(e) Work covered by this application may not commence before issuance ora Highway Excavation Permit by the Town Clerk.
6. Tax Map No: District 1000 . Section . Block , Lot
7. Starting Date: 10/24/16 Completion Date: 10/25/16
8. Work Schedule: Phnce Completion Date
Excavation Wo k Schedule
Facility Installation 119ust be provided
Backfill&Completion for consideration as a
Pavement Replacement Complete Application.
9. Under which authority is application being made: Keyspan Gas East Corporation d/b/a National Grid
See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified.
10. Estimated Cost of Proposed Work: S
11. Remarks: install new gas service
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:
$1,000,000 per Occurrence and S 2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided In the total Amount of$
(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 bf Project Locations shall be subject to the approval of the Highway Superintendent.
Al. /Service Connections excavations @ 520.00 $ 20.00
No.
A2. /Additional Excavations same service @ S 10.00 S____,_
No.
B. Excavations 18"in depth or less
0-100 L.F.=$10.00;Additional L.F.@$0.10 S
C. Excavations 18"in depth to 5' in depth
0-100 L.F.=$30.00;Additional L.F.@$0.30 S
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
TOTALS 170.00
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:
_ in accordant vith
this application and subject to the"General Conditions"and"Special Conditions"of permit a )altac d veto.
SUPERINT WAYS
TOWN OF O V YO
' cent M. ndo
Date
Date Received by the Town Clerk I V e
Date Permit Issued o 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)
INSPECTOR'S RE,CMS
Inspection Date Findings(use code) Applicant Notified
1St
2nd
3rd
4th
(To Permit Clerk)
RE1b1ARI�S
QQDE
IS 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/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR „
1. Permittees Contractors to Comply with Permit Requirements: The Permittee is responsible for
informing its independent,cooti�actors,'cmployces,agents and assigns of their responsibility to comply with
,this permit, including all special/site specific and general,condiiions imposed by`the Highway
Superintendent while acting as the psrmittee's agent with'respect to the'permitted activities,and such
persons shall be required to comply with all permit iequirerrients.
2. 'No RiAt to Tresonss or Interfere with Privnte Pro 6rty Rights:"This permit does not convey to the
petmitteeany right to trespass upon the lands of adjacent property owners in order to'perfurm the permitted.
work nor does it authorize the impairment of any'rights,title,or intgrestin real or personal property held or
vested in a person pat a`party to the permit,
3. Protection of the Ili jIg way rind Future Iliehway Mnintenance: 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,
structrire,Ell;'excavation,of other modification of the highway hereby authorized shall not be completed.
Additionally,the permit may be'revoked,if the Highway Spperintendent finds that the issuance of the'
permit'was illegal or unauthorised or that the applicant failed to comply with`any of the terms and
conditions of thepermit'or Chapter 237 of the Town Code,
4. Revocation of the Permit by(lie Iliebway Suricrintendent: If the Highway Superintendent deems it
'rev
necessary t oke 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 acid manner as the Superintendent
may require,,remove all arany portion of the uncompieted utility,structure or fill and restore the site to its
former condition.
5. Notice of Commencement: At least,24 hours prior io'commcncernent 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 perTriit. Upon completion of the'work,the contractor
shall provide photographs of the corripleted work to the Town Highway Department,and request a Final
inspection.
6. Storage of Eg`uipnient&Materinis: The storage of construction equipment and/or materials shall be
confined within the pro 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 Marti-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 it the contractor's expense.
8. Road Closures: All scheduled road vlosures'must first receive written peradssion from the Southold Town
Board prior to closing a road. Temporary lane closures may be permitted,with'the approval oFthe Highway
Superintendent. This iters will included but not be limited to the installation of appropriate signage and
flag men to stop and start traffic to a11ow for single lane traffic . Road Closures due to unforeseen'
emergencies require immediate-notification of the Highway Department and'shail be limited to immediate
and/or expedited restoration of the Work Zone,
9. No Construction'Debris in Road Slioulder'Area: !All Construction Debris shall be removed from the job
site on a daily basis,"All-stockpiled soil is well-as all other project materials that will be staged within the
/tight-of Way must be delineated with reflective signage or other means to meet the minimum requirements,
of the NYS DOT Construction Standards.
GENERAL,CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR 1-UGHWAY 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.
It. Clean Till 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. Ali 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_lor jute matting until weather conditions favor
germination.
13. Baelctill&Compaction of nil 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(12'1 inches thick and shall be mechanically compacted to a Ninety-
five(95°1x)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. ReOoriition 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. Schentntic Pions with all Technical information and Scope 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.
16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner;
(Note:When Concrete Pavements aro 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;
c) 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. Trenching of Pavement Surfaces Txceeding One Hundred(1001 Teet in Length_ All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
P 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(21) inch lift of Asphalt(Type 6)`nearing Course(Typical,shoulder to shoulder).
vi ty
ihl : ` .
P-4 PERMIT A 1MI ►TIO1I IKETCH- rn
Vi'llage-Of
.DATE: 911612016
LOCATION:- 1375 AOKERLY PONE61&blss STREET 1: LOUVER RD �
TOWN:- SOUTHOLD CROSS STREET s:
WORK ORDER: T101884423
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* * * RECEIPT * * *
Date: 10/04/16 Receipt#: 213679
Quantity Transactions Reference Subtotal
1 Excavation Permits 1159 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#35955 $17000 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, 1159