HomeMy WebLinkAbout475 Hill Rd Permit No.
TOWN'OF SOOTHOLD
HIGHWAY DEPARTMENT
Peconic Laine
fi
-Pe' ot i_ ,New,:Yorkl,1958.
T10189970 .' (613i)1,65-3140,
:APPLICATION/PERMIT FOR HICIIWAY EXCAVAT[ON AND'REPAiR`; ;
APPLICATIMIS HEREBY made"to the Superintendent of Highways of.the Totvn of Southold for the'fssuonce of an Excavation Permit.•
pursuant to_Cliapter 237,of the Code,of 1he,Town of,Southold;�Suffolk Couaty,-N'W-Wrk,�and other applicable laws;ordlnances or
regulation's for each individual contiguous excavation project herein_descrlbed;!The applicant agrees to comply Mth,ull applicable"lava;,
ordinances',codes'cind'regulations;the attached"General Conditions of Permit"and°Special Conditions';ifany and to permit authorized
'inspectors to make necessary inspections of the job site.
Print or'I'vnc "Keyspan'Gas.•East`Corp.D/B/A-'National Grid
Gas Permits'Dept.'Bldg: 3'FI': ,1_ _
5,16 545 4094, 175,1, Old^CountryRd,Hicksvillei NY 11801
Name of Applicant - PhoneNumber Address of Applicant
-Name of Contractor, Phone Number :i Address ofContractor ;
3.
Name of Property Owner Requesting Service(if applicable) ;Address of Owner,
475 HILL RD W N/S, 300'.W/O'HARPER RD
Work,'Description and Location(Street Number,Hamlet,Cross Street)'
(a)' Is construction,16cated-within,75 feet of tidal wetlands?, *Yes' ;No,
*If yes;other Town permits may be required., "
.Nlargaret'Pagl,ia "W4a
NOTE: All fnformation-requested by this Signature of Applicant
Applledtion Y Permit Form-'is
Required,for a complete-application! 1/10/17
Date,
5. (a)"Attached plot pian to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the,
location'of all proposed excavations drid.relotionship to adjoining premises;public streets or areas;and give a detailed description of
all site'and pavement restoration work.
(b)" Attoch ull,other necessary permits and licenses for this'project, ;
(e),Work covered by this applic6tion may,nofcommence'before issuance of n Highway Cxeavalon Permit•by the Town Clerk.
6., TaY Mnp No.: District 1000 . Section` ` . Fliock Lot ;
7:- Starting Date:"
2/11/17 Conipletiom'Date. 2/12/17 '
8. Work Schedule: a Phase Completion Date ,
Excavation 'Nark Schedule
Facility Instal}ation -i1]ust be provided .
Backfill'S,Completion for consideration as n
Pavement Replacement Complete Application.
9. Under which authority is appllcation beWg'made: K2y'span-Gas East Corporation d/b/a National Grid
See Town Code Chapter 237,(E)-Provide Aesolution by,�or-authority from,the,Utility being inodif led.
10.',Estimated Cost of Proposed Work: 'S'
11. Remarks: OPEN (1) 4-Ml GRASS BELL HOLE-TO INSTALL,GAS SERVICE
:D-39- : . 1: of _3;
12. Insurance Coverage:(Attach Copy)
(a) Insurance Company:
(b).Policy H:'
(c)State whether policy of certification on fife with the Highway Department:
(d)Coverage i equired extended to theToWii:
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 S
(b)Maintenance Bond,provided:, 2 years or, 3 years.
14. Fees for Applications and permits:
Basic ApplicatiofiTee 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 S 20.00
No.
A2, 1 Additional Excavations same service,@$10.00 S -
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;Additionni L.F.@$0.30 S,
D. Excavations 5'in depth and over
0-100,L.F.=$50,00;Additional L.F.@$0.50 S
E. _Utility Repair Excavations @$10.00 S
No.
Repairs some 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 caVation permit to:
in accordance ith
this'application and subject to the"General Conditions"and"Special`Conditions",of permit If any attac to.
SUPERINT I) AYS
TOWN OF OL YOR
Date
Date'Received by-the Tow Clerk
�3 l
i �Cgg
DatcTeriitIssued `� PermitNo.
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,C®RDS
Inspection Date Findings(use code) Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
113 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 orExcavation
RFR Ready for Repair
D-39 3 of 3
GENERAL CONDITIONS OF PERMIT:'
APPLICATIONI HERMIT FOR HIGH`'VAY-EXCAVATION AND REPAIR
1; Pcrrnittec'a Contractors to Corgplywithi� ermk Reapircrttents: The Permittee•is responsible,for
informing its independent contractors,,employees,'agents and assigns of their responsibility.to comply with
this;permit, including all°'speciaUsite specific and;gene'ral conditions imposed by the Highway..
Superintendent while acting-as the permittce'i agent with respect-to'the permitted activities,and such
persons shall be required to comply,With all permit requirements.
2, No`Ri ht-to.Tres •ass or Intorfere with Private Pronertv Rights:"This permit docs'not convey to the '
permittee any right to trespass upon the lands of adjacent property owners in order to perform the permitted
work nor does it authorize the impairment of any rights,title,or-interest in real'or personal property field or
vested in a person not a pariy,to the permit.
3. Protection of the Iliphivav and Future Iiig.Invay Maintenance: If future operations or highway
maintenance projects by,theTown of Southold require an,alteration in the,position of the utility,structure
or work herein authorized;or ifJn,the'opinion of.the Highway Superintendent tltc work performed under
this'.permit shall cause unreasonable obstruction to required highway maintenance or endanger the health,
safety arid/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 permit may 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; Revocsition of Ilse-Permit by the Highway 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 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 Commencement: At Icast 24 hours prior to commencement 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 thispermit. 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-&Materials: 'The storage orconstruction equipment andlor:materials shall be
confined within the projectwork area and/or adjacent areas where permission/legal_access has been
obtained'in a manner that does not interfere with normal highway traffic.
T. Utiiity Mnrh-Ours: ;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 at the contractor's expense.
8. 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-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.
g, No Construction Debris in Rond Shoulder Area: WI Construction Debris shall be removed from the jab
site on a daily basis. All'stoekpiled 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.,
J
GENERAL-CONDITIONS ORkE,RMIT
APPLICATIONMERMIT FOR'I-IGHWAY EXCAVATION AND REPAIR
.(Continued)
10.Install,Maintain Erosion Cantrals:•Required Erosion Control Measures(i.e.silt fenciiig)•is to be placed
on the downslope edge of any disturbed'area. This sediment barrier is to be put inplace before any
disturbance ofthe ground occurs`and is to be maintained:in,good'functional cofditio ntiI thick.vegetative
cover is established.
11. Cleain,Fill-Only: All project back-fill shall consist of clean sand,gravel-or soil(NOT asphalt,slag,flyash, "
broken concrete o�'demolition debris).:-All unsuitable Soils excavated at the site(i.e.Clay,Bog,,etc.)are to
be removed fr'om'the'sitc"and not used to backfill any excavation within a'Town•Highway:
12. All Areas of Soil Disturbance: Ali'areas of soil disturbance resulting from the approved project"shall be -
stabilized to the satisfaction of the highway Superintendeni 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•siabilized with straw;haym
, ulch,and/or jute matting until weather,conditions favor
germination.
13. Ba'didilIA'Comilaction orn11 Excavations: Back Fill shall consist,of clean fill or soils which exhib'tt'a
well=defined moisture density reladonshi"as determined to be in accordance with ASTMD 698. Fill shall'
be,placed in maximum lifts of twelve(12”)in6hes thick and shall be mechanically compacted to a Ninety-
,placed
(95a/a)percent tnaximum'dry-density. Suitable hydraulic compaction by waterjetting atthree=foot
intervals will also be permitted subject to a project specific approval by the Highway Superintendent.
14. Restoration of the`Road-Shoulder'Arca.1'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&privateroad aprons;mail boxes;sprinkler systems,trees and orntimental 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 satisfactioai of the
Highway Superintendent.,
15. Schematic Plansiwith all Technical laformation,and Scone of Worlt:-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 andlor concrete pavements. Accurate size of bell holes or width
of trenching must be indic"ated by dimension or labeling.' This schematic site plan,must provide details on
all restoration"required to meet the requirements of these General Coriditions,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 alt back-fill,&soil compaction work'as needed to provide n 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) Instill 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 Exceeding One nundred(1001)Feet in Lengtlit"All trenching of
pavement surfaces exceeding 100',in length must first be reconstructed to meet the requirements of Item
N 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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a id-
'PERMT A MCATION SKETCH
Village Of
DATE: 1110/2017
LOCATION- 475 HILL RD GROSS STREET 1: HARPER RD 3
bA
TOVM- SOUTHOLD CROSS STREET 2: MIDFARM RD
WORK ORDER: T101899706
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-SURFACE:
Grass/Dirt Houm'NO.
475
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300' v
4'x'4' Bell Hole �
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HILL RD
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* * * RECEIPT * * *
Date: 01/17/17 Receipt#: , 215739
Quantity Transactions Reference Subtotal
1 Excavation Permits 1189 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#36433 $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
Clerk ID: BONNIED Internal ID. 1189