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HomeMy WebLinkAbout645 Westphalia Rd (3) �f \ - + 'L * * * RECEIPT * * * Date: 10/21/16 Receipt#: 214025 Quantity Transactions Reference Subtotal 1 Excavation Permits 1166 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#36176 $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 Bld 3 FI 1 Hicksville, NY 11801 Clerk ID: LYNDAR Internal ID: 1166 � y r Permit No. RECEIVEDTOWN OF SOUTHOLD gUFFOI,E HIGHWAY DEPARTMENT Peeonic Lane OCT 2 0 201 ' Peconic,New York 11958 0 T101889793 (631)765-3140 Southold Town Cfer APPLICATION/PERMIT FOR HIGITWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Tawn 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 orI:M Keyspan Gas East Corp D/B/A National Grid Gas Permits Dept. Bldg: 3 FI: 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. 645 Westphalia Rd, Mattituck- S/S, 100' E/O County Road 48 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. Margaret Paglia NOTE: All information requested by this Signature of Applicant Application/Permit Form Is Required for a complete application! 10/11/16 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 ror this project. (e) 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 16 7. Starting Date: 11/09/16 Completion Date: 11/10/16 S. Work Schedule: Phase Completion[late Excavation Work Schedule Facility Installation Must be provided Backfill S 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: $ ll. Remarks: REPAIR GAS LEAK D-39 1 of 3 12. Insurance Coveiage:(Attach Copy) (a) Insurance Company: -- (b) Policy fit: (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extepde'd to the Town: Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed: $1,000,D00", Occurrence and S 2,000,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided In the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Applications and permits: BA51C Application Fee far Each Project Location - $150,00 A Project Location tivould include each Bell Hole andlor every road opening or excavation within any 50'Radius whether'a not they maybe inter-connected by open trench or directional baring. The total number of Project Locations shall be subject to the approval of the Highway Superintendent, Al. !Service Connections excavations Q$20.00, S20.00 No. A2. _/Additional Excavations same service Q 510.00 S No. B. Excavations IS"in depth or less 0-100 L.F.=$10.00;Additional L.F.Q$0.10 S C. Excavations IS"in depth to 5' in depth 0-100 L.F.=$30.00;Additional LY.@$0.30 5' D. Excavations 5'in depth and over 0-100 L.F.=$50,00;Additional L.F.Q$0.50 $ E. Utility Repair Excavations Q$10.00 $ No; Repairs same service Q$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 accordance ivi this application and subject to the"General Conditions"and"Special Conditions"of permit(if y)attache ere . SUPERINTIriV T S TOWN OF SO I! RK Virkent h M. ' "Daft Date Received by the Town'Clerk I D ' ' Date Permit Issued 0 - a t Permit 140. 0 G 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: 1 Permit# 1 Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 1st 2nd 3rd stn (To Permit Clerk) REMLRKS CODE 1B 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 PEI RMT APPLICATIONMERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Permittee'.Contractors-to Coninlywith Permit Reguircinicnis: The Permittee is responsible for informing its independent contractors,employees;agents and,assigns of,their rc5ponsibility to comply with this`peimit,�including all special/site specific and general conditions`imposed by the Highway Superintendent while acting as the permittee's agent with respcctto the permitted activities,and such persons shall be required,to' comply'with all permit requirements.• 2. No Rig ht to Trespass or Interfere with-PrWhtIe Property 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 nofd6es'it authorize the impairment of any rights,title,-' interest in real or personal property held or vested in a person not a party to the permit., 3. Protection of the I ighwav and Future Iliefiwny 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 lie.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 Superintendentfinds 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 by the Hiehwav SuperintendentIf the Highway Superintendent deems it necessary to revoke this permit and the project hereby authorized has not been completed,the applicant shaft,without'expense to the Town and to such extent and in such time and mianner'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 Comimenccment: At least 24 hours prior to commencement of the project,the pertnittee and/or contractor shall notify the Town Highway Department in writing that they are fuily 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 workto the Town Highway Department and request a Final inspection. 6. Storage of Equipment&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 ina manner that does not interfere with normal highway traffic. 7. Utility Mnrk-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility mark=outs and shall take ull precautions to protect same. Damage to existing utilities shall be the responsibility of the contractor and shall be repaired at the contractor's expense. S. 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 triflic to allow for single lane traffic. Road Closures due to unforeseen emIergencles 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 Rand 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 meet the minimum requirements of the NYS DOT Construction Standards. a GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT.FOR HIGHWAY EXCAVATION AND REPAIR (Continued) 10. Instill.Maintain Erasion Controls: Required Erosion Control Measures(Le.silt fencing)is to be placed an the„downslope edge"of nny'disturbed area, This sediment bairier is to be put in place before any disturbance of the ground occurs and is to be inaintained•in good functional condition until thick vegetative cover is established. 11. Clean Till Only: All project back-f:ll shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash, broken'concrete oi'demolition debris). All unsuitable soils excavated at the site(i.e.Clay,Bog;etc)are to be removei from the site and not used to backfill any excavation within aTown Highway: 12. Ali Areas of Soil Disttirbance: Alf areas'of soil disturbance resulting from the approved project shall be stabilized to the satisfaetioti of the`Highway Superintendent immediaiely'followingproject completion. If the p0ject 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. l3:ictctill&Coin of nu Exenvations: Back Fill shall consist of clean fill or soils which exhibit a well-defined moisture densiti 'Mation`ship as deteimined to be in accordance with ASTMD 698. Fill shall bo placed in makimutn'lifts of twelve(12')inches thick and`shall be inechanicully ” 'ompacted to a Ninety- five(95%)percent•maximum drydensity: Suitable hydrnulic compaction by.water jetting at three-foot intervals will also be permitted subject to a projecf specific approval by the Highway Superintendent, 14. Restoration of the'Rdad Shaii1der Areit: Allman-made improvcinents located within existing road shoulder area's must be protected to the greatest extent practical. Items would include butnot be limited to driveway&private road aprons,snail boxes,sprinkler systems,trees and ornamental plantings. Excavations thr'ough'drivewiys and private road pavements mnust be reconstructed to meet all requirements of Southold Town Highway Specifications: All pre-existing road shoulder improvements that havii been disturbed during construction must b'e replaced or repaired by the contractor to the satisf iction'of the Highway Superintendent. 15. Schematic Plans with till Technical information tied Scope of,Work: To reasonably and adequately describe iha 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 oftrenching 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 requirement`s found in the Southold Town Highway Specifications. 16. Pavement Reconst'ruc`tion: All Pavement sections must be reconstructed in the following manner; (Note:When Concrete Pavements are Present,Pic-ase 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 twb 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. Trenchinti of Pnventent Surraces Exceedina One Hundred(100')74cct in Length: All trenching of pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item 0 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). . sj iy JOA-0/Z1516 04 :05 ' (UTC/GMT) ,National Grid page 2 J IA7i'oOL GRID REQUEST FOR STREET OPENING PERMIT -NASSAU SUFFOLK S©yTNOLD FC-6111.4 ❑ STATE .[I COUNTY ❑ COUNTY. PERMIT MIS JOB p'Do �} DATE l o�PE ►�`{'A !A- W.O./PA FORE AN DATE OF NO. OPENING REQUESTED ` v DEPARTMENT ' DIVISION BY �7• KpacI�-� GAS CONSTR.MAINT.&SERVICES DATE APPROVED SKETCH [� J