HomeMy WebLinkAbout2655 Calves Neck Rd Permit No: 1 ��
TOWN,OF SOUTHOLD. .
.HIGHWAY-DEPARTMENT
-Peconic-Lane
Peconic,New,York 11958 p ,
T101918491 (631)765-3140
APPLICATION/PERMIT FOR HIG1iWAY,TXCAVATI0N AND RRPAJR
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 C6de of the Town of Southold;Suffolk County;New York,'and other applicable iaws;,ordinuitces or
regulations for each individual contiguous excavation-project herein-described. The applicant agrees to comply with all'applicWe laws,
ordinances,codes and'regulations,the attached"General Conditions of Pecmh'and"Special Conditions",if any and to permit authorized
inspectors to make necessary,inspections of the jab site.
PrintorT�mc Keyspan Gas East Corp D/B/A National Grid
Gas-P&mits DOpt. Bldg: 3-Fl: 1
1. 51'6 545 4094 175 Ei 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. 2655 CALVES NECK RD, 140' E/O HARPER RD
Work Description and location(Street Number,Hamlet,Cross Street) ik
(a)''Is construction located within 75 reef of tidal*etlands7- *'Yes, No
*If yes,other•Town permits may be required. � � r
Margaret Paglia
NOTE: All information requested by this Signature of Applicant U
Application/Permit Form is
Required,for a camplete applicatlonl 1/10/17
- 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
nil 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 of n Highway Cxeavation Permit by the Town,Clerk.
6: Tax Map No.: District 1000 . Section -Block . Lot
7. Starting Date: 2/11/17' Completion Date: 2/12/17
8. Work Schedule: Phase Completion Date
Excavation War c Schedule
Facility,Installation Must be provided
Backrill&Completion for consideration as a
Pavement Replacement Complete,Application.
9. Under which aulhorityis application'being made: Keyspan Gas East Corporation d/b/a National Grid
'See Town Code Chapter 237(E)-Provide Resolution by;or nuthority,from,the Utility being modified.
10. Estimated'Cost of Proposed Work: S _
11. Remarks: OPEN (1) 4'X4';_GRASS''BELL HOLE
D-39 ry 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:
S 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 numberbf Project Locations shall be subject to the approval of the Highway Superintendent,
Al. /Service Connections excavations Q 520.00 S 20.00
No.
A2. /Additional Excavations same service(Qa $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;Additionui L.F.@$0.30 S
D. Excavations 5'in depth and over
0-100 L.F.=$50.00;Additional L.F.Qa $0.50 $
E. Utility Repair Excavations Q$10.00 $
No,
,Repairs same service Q$5.00 $
Additional
TOTAL$ 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 with
this application and subject to the"General Conditions"and"Special Conditions"of permit(' a )at a ereto.
SUPERINT F HW S
TOWN OF I L �tiV RK
Vincent a
II ate
Date Received by the Town Clerk l -41
Date Permit Issued 1 I—t Permit No. 1 ` -
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(rise code) -Applicant Notified
151
2nd „
3rd
(To Permit Clerk)-
RKMARKS
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 of Excavation,,
RFR Ready for Repair
D-39 _ 3 of 3
=I` .,,GENERAL'CONDITIONS OF:<PSRIVIIT -
`.;APPLYCATION/PERMIT FOR HIGHWAY`EXCAVATIONREPAIR
' •1, �Pcrmiftee'a Contr7ictors'to Corm`nlvsvii6Permit Rnniiirciiien'ts:,Tlie Permittee is respoitsiblefar. -
�-infb ming its"independent con tractors:cmployees;iigents and assigns:of their responObHityso comply with -
AisperIin including"all speciallsite specific and gencral-conditions'imposed by tliaighway,•
Superintendent while acting'as the permittee'"s agent with respeefto""the permitted activities;,and such .
persons shall be required`,to comply.virith all permit`requirements.
2:, No'Rielit to Tr`"esnhss or Interfarazvilh Privsite 1'ro»erty'.Rights: This'permit does not convey,to the
perniitteemy;right to trespass,uponthe lands of"adjacent property owners.in•order,to_perform the,permitted ;
work nofdoes it authorizeJhe impairment of any rights,title,or interest in real''or'personal'property-held or
vestedin; a persorihot a paiiyto the permit.,•
:Protactian of the Iiighwav and Tuture Iisla�4�a �'Mnintcnance: If future operations:or highway
maintenance pr=d`6iif,,ifi-thbopini6n
the Town'of Southold regWre'an alteration in the;position of the utility,structure .
or worlC arein of the Highway Superintendent`thework perforrtied"under _
this permit shall cause unreasonable_ob'struction to required highway maintenance•or-endanger-the health,
,safety and/or welfare of;vehicular,or pedestrian'tiaffic;this peimit'shall be'revoked�and the utility,-
structure,`fill;cxcavatiot%or other modification of the highway herebyauthbrized shall not be,completed.
Additionally,`the per6it'may be.•rcvokcd if the Highway Superintendent finds that the issuahce,of the'
permit was'illegal or unauthorized,or that'tlie•applicant failed to'comply iAh any of the terms and,
conditians•ofihe permifor`Chapte�;23Tof the.Town Code.'
A,. Reybchtion of lire Permit by`ilte'IIiehwav•Suneriniendent;_If the Highway Superintendent deems it
necessary' 'to revoke this perinit`and the project hereby-authorized has not'been completed'the applicant'
dull,without expense to the Town,and.to such extent and,in'tuch`time and manner as the Superintendent -
may require,remove all orany p"Mon'of the uncompleted.utility-structure or fill and 'restore the site to its -
former condition.
5., Notice of Commencement: At lcast`24 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 rind
understinM allterm and project conditions' this permit. Upon cor ipletion of the work,,the contractor
shall°providd'•photographs of the completed work-Io the-Town Highway Department and request a,Finat
inspection.
6. Storstee of I:ttuinment&Ma'terlaisr•The storage ofconstruction equipment'andlo' materials shall be'
Stor ed,within't}ie,project work area and/or adjacent-.areas wliere,pernihslon/legal access has been,-
cbnfiobtained in a manner that.does not interfere with-normal,highway,traffic. _
7,,,Uiiiiiy Mnrh-Oiits:=The Applicant/Contractor shall`be responsible for verification of all existing utility•
mark-outs and,shill,take'all`peccautions to protect same: Damage to existing utilities shall bathe .,
responsibility-of the'contractor.and shall be,repaired;at the contractor's expense.,-
K -Road Closures:=All schcauled'roud,clvsures mutt'first receive written permission from the'Southold Town
Board prior to closing a:ioad..Temporary lane closures maybe permitted with the,approval of the Highway,
Superintendent.,This itent'will included but not be limited to the'installation of appropriate.signage and
flag men to stop and;start traffic to allow fdr single lane traffic'.. Road.Closures due to ,utiforeseen .
emergencies require immediate notification of the'Hight ay Department and shall be limited to•immediate,
andlor expedited restoration of•the Work Zone.
g, Na Can struction'Debris'iia Road SI tuulder.Area: All'Construction Debris shall.be:removed from the job'
site'on a,daily basis. All,stockpiled soil as well asIll other project material's that will be staged witliin,tlie
Right-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,PERMI'I'•: =
APPUcATION/PERMIT FOR HIGHWAY°EXCAVATION AND
REPAIR,,
(Continued) ;
l`p,'•Instnll,,Maint:tin"Erosion Controls:•Required Erosion Control Meisures.,(i-e,.siltfencing)is to be placed
on the downslope edge.of any disturbed area.-This sediment barrier is to be put in place,bt:fore any
disturbance of the ground'occurs and is to be maintained in good functional'condition until thick'vegetative ,
cover is established: ;
A 1:"'Clean•h'ill 0nlv:,All'projcctbackdill shall,consistofclean sand;gravel orsoil(NOT'asphalt,slag,:flyash,
"broken xoncrete or'demolition debris).,-All 'unsuitable soils.-ekdavated'it the site_(Le Clay,Hoggetc.).are'to ;
be removed from the site-and not used,'to.backfill any excavation within tiTown Highway;,, -
12.' AII Arcas~df Soil 1)isturliance: :Alf areas of soil disturbance resulting from the,approved,praject shall be
" stabilized to the satisfaction-of the Highway.Superintendentimmediately folbwing project completion. 'If,
tlic.project site remaip's'inactive,for.more than-48, planting is impractical`due,to the,season'Alten`
the area shall be stabilized with straw;hay.muich and/or jute matting until weather conditions favor,
germination.
13, Bn`elcfill&Compaction of nil Ex,cavation's: ,Back Fill shall consist of clean fill°or soils which`exhibit,a '
well=defined moisture.density relationship as detetinined to bein accordance'with=ASTMD-698: Fill shall
b'e_plaeed in maximum lifs,of twelve(it)inches'thick"d shall be mecliariically.comoacted•to a Ninety-.
five(950/a)percent maximum dry density. Suitable hydraulic compaction'by�water jetting'attliree-foot
intervals will-also be permitidd subject to a project specific approval;by ilte Highway'Saperintendent;
'14.,Re'stoeation of�tli'c Road Slroulder�Aren: All man-made improvements,located within existing road
shoulder.areas must be protected to the greatest extent practical.,"Item's would;include'but not b'e limited to
driveway'&-private road aprons;,mail boxes;sprinklcr'systems,trees and ornamental plantings:. .
Excavations through'driveways;and,private road pavementimust be reconstructed to meet all requirements
of Southold Town Highway;Speciftcatio'ns, All-pre-existing road shoulder improvements,that have been
distu ci d`duringconstruction must_be replaced or:reptured.by the contractor to.the satisfaction,of the,
Highway,SuperintendenL
15. Schemntic Plans with al]'I'echnica!information-nnd Scope of Work: To reasonably and adequately, .
describe the proposed work;accurate schematic site plans,must be provided toshow'-.indicate all ,
proposed construction'activiiy iequiidd under this piifdit. All Pnvementsurfaces scheduled for excavation
must be`saw cut•to the full depth of asphalt and/or concrete pav6mefits..Accurate•size of bell holes or,width
of trenching must be indicated by,diinension or labeling:,-This schematic site plan must proAdc,d'etails on
all restoration required to meetthe r6i uirements of these General Conditions and-requirements found•in-the
Southold Town Highway Specifications:
1,6. Pavement Reconst'r'uction::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'&�soi!compactionwtiork 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 Blerid.base(RCA Blend must meet NYS DOT,Specification);
d); Install a`two.and orie'lialf(2.5'•')'inch compacted lift;of•Asphalt Base Course;
c)-Install a one and one'half(1,5")inch of Asphalt(Type 6)Wiaring;Course.,
'{Provide AC at all j'ints) '
All work listed herein-must meet thc.tninimum-requirements of;the Southold Town Highway
Specifications..'
17. Trenching of Pavement Siirrades Exceeding Onel7untlretl 100' Fcet•in Len the Allttrenching of
pavement surfaces exceeding,1'00'.in-length must first be reconstructed tomeet 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 lengthW trench'shall be
repavt3d.with'a•two(2").inch-lift of Asphalt(Type 6).Wcaring Course,(Typical,shoulder to,shoulder)..
s)�y
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TERZ1+ITUAP_MICATION:SIOTCH
Village,Of
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'DA TE; 111012017 83
LOCATIOK:. A56 CALVES NECK ROMSSTREET I: HARPER-RD 0
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Town: 8C7UTH0'LD CROSS,STMET2-, HARPER RD
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* * * RECEIPT * * *
Date: 01/17/17 Receipt#: 215738
Quantity Transactions Reference Subtotal
1 Excavation Permits 1188 $170.00
Total Paid: $17000
Notes:
Payment Type Amount Paid By
CK#36913 $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. 1188