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HomeMy WebLinkAbout1270 Skunk Ln Permit No. 1 TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peeonic Lane k ; Peconic,New York 11958 o� T101896605 (631)765-3140 APPLICATION/PERMIT FOR HIOIiWAY 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 applica:It,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'vne Keyspan Gas East Corp D/B/A National Grid Gas Permits Dept. Bldg: 3,FI: 1 l 516 545 4004 175 E. DEd,Country Rd HIckkvillej 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 1270 SKUNK LN; CUTCHOGUE- E/S, 1250',S/O MAIN 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. Margaret Paglia - 001. NOTE: All information requested by this Signature ofAppiic t ✓1� Application/Permit Torm Is V� Required for a complete applicatloul 10/28/16 - Date y 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,thls project. (c) Work covered by this application may'not commence before issuance of Highway Excavation Permii by the Town Clerk: 6. Tax Map No.: District 1000 . Section" . Block Lot • 11/27/16 Completion Date: 11/28/1 7. Starting Date '6 S. ,Work Schedule: Plsasc Completion 1)stte Excavation W4009chedule Facility Installation Must 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. lb. Estimated Cost'fProposed Work: 11. Remarks: INSTALL GAS SERVICE D-39 1 of 3 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: (b) Policy P: (c)State whether policy of certification on ftie 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 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 @$10.00 S No. B. Excavations 18"in depth or less 0-100 L.F.=$10.00;Additional L.F.Q$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.Q$0.50 $ E. Utility Repair Excavations Q$10.00 S 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. 4 4 4 4 4 • 4 M • 4 4 4 ; 4 Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: in accordance v ith this application and subject to the"General Conditions"and"Special Conditions"of permit any)attach h to. SUPERINTE D F A TOWN OF YO K Vince nt/ r� o Date b Date Received by the T1own Clerk Date Permit Issued �)APermit 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 RECORDS Inspection Date , Findings(use code) Applicant Notified 1s` 2nd 3rd 0 (To Permit Clerk) REMARKS CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due to backfilling BUG 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 t GENERAL CONDITIONS OF PERMIT. APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Pcrmiitce's Contractors'to Comply witli Permit Recti lr`einents The Permittee is responsible for informing its indepondent'contractors,employees,agents and assigns of their responsibility to comply with this permit,including all special/site specifc 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 Right to Trespass br Intcrfe'rc with Private Pronerty Malits: 'This permit docs not convey to the permittee any right to`trespass upon the lands of adjacen't property own'er's in`ordcr to perform the permitted work nor does"it authorize the impairment of any rights,title,or interest in real or personal property held or vested in a person not a party to the'penfi t, 3. Pi otection of the Uighivay and Future If iehway 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 permifia'y 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 by the iiittbifav 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 asthe Superintendent may require,,removc all orany portion of the uncompleted utility,structure or rill 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 tiro fully aware of and understand all terms and_p roject 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. Storage of Equipment&Matcrinls: 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 docs not interfere with normal highway traffic. 7, Utility MnAc-Outs: The Appiicant/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. S. RoadClosures: 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 mento stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen emergencies 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 Slwulder Area: At.]Construction Debris shall be removed from the jab 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. 1 } GENERAL CONDITIONS OF PERMIT APPLICATION/PERAUT FOR HIGHWAY EXCAVATION AND REPAIR (Co-htinued) 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 oi'demolition debris). All unsuitable soils excavated at the site(i.e.Cky,Bog,etc. )are to be removed from the site Lind 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 favor germination. 13. Baelcfill&Compaction of'fill 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(I2'1 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 peiznitted subject to a project specific 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;greatesi 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 satisfactiori of the Highway Superintendent. 15. Schematic Plans with all Technical information rind Scone orMerk: To reasonably and adequately describe`the proposed work,accurate schematic site pians must be provided to,show_or indicate all proposed construction activity required under this permit. Ali 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 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(121 inches on all sides; c) Install a compacted Iit}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. Trenching of Pavement Surtaces E xceeding One Hundred 100' Tcet in Lengths. All trenching of pavement surfaces exceeding 100' in lengtli 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). s'ty ntion .l r 00 N a MR1%M "M11CATICN SKETCH Village Of DATE: 10/28/2016 LOCATION: 1270 SKUNK LN CROSS STREET 1: MAIN RD ) T ONM: CUTCHOGUE CROSS SPREET 2: EUGENE RD WORK ORDER: T101896605 d^' 0 SURFACE: � Macadam Roe d ry Howe NOL M 1270 `^ w < W A � � o D Wrn rn cam• CL- ai bn cd 1261' 4x 4' Bell Hole U N �i SKUNK LN 3 * * * RECEIPT * * * Date: 11/22/16 Receipt#: 214536 Quantity Transactions Reference Subtotal 1 Excavation Permits 1178 $170.00 Total Paid: $170.00 Notes: Payment Type_ Amount Paid By CK#36360 $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: BONNIED Internal ID. 1178