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Home My WebLink About1625 Indian Neck Ln Permit No: �u TOWN F SOUTHOLD HIGHWAYODEPARTMENT ��®�pgufFOt,f�oG� Peconic Lane Peconic,New York 11958v T101922967 (631)765-3140 :1 APPLICATION/PI:RmIT I:OR HIGIiWAY EXCAVATION AND RT:PAIR 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 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 orTyp 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, IVY 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 1625 INDIAN NECK LN, PECONIC E/S, 390' S/0 SPRING LN 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 &��4444: NOTE: All information requested by this Signature ofAppi ant Application/Permit Form is Required for a complete application! 1/19/17 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 all site and pavement restoration work. (b) Attach all other necessary permits and licenses for this project. (c) 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 7. Starting Date: 2/18/17 Completion Date: 2/19/17 8. Work Schedule: Phase Comnletion[late Excavation Work Schedule 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. 10. Estimated Cost of Proposed Work: S .�.______—_ 11. Remarks: OPEN (1) 4'X4' MAC BELL HOLE TO INSTALL GAS SERVICE D-39 1 of 3 12. 'Insurance Coverage:,,(Attach,Copy) (a) Insurance Company: (b) Policy,#€: (c)State whether policy;of eerarication'on fife with the Highway Department:" •a• _ (d}Coverage required extended to,the'fown: � - ' -' - ,_ - ' - , Any Loss including Bodily injury,-property or commercial,injury caused by or attributable to tie work performed: $1,000,000"pec Occurrence and S 2,000,000 general aggregate. 13:.Securiy: (a)-Surety Bond or-Certified Check -provided-in the total Amount of$ - (b)Maintenance Bond provided: s2 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 andlor every road opening or excivatign within any 50',Radius whether:or"not they may'b i "ecmected 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 520.00 S 20.00 No. A2. ��!Additional Excavations same service(3a 510.00 • S ; No. , 13. Excavations 18"in depth,or less 0-100 L.F.=$10.00;Additional L.F.Q$0.10 n , C. -Excavations I S"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.K,-$50.00;Additional L.F.©.$0 50 $ E." Utility,Repair Excavations_@-S16.00 S 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' ccordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if an attached hereto:- SUPERINTEND Hl TOWN OF SOUT K n nt Ni,Orlando ( Date' Date Received.by the To%VQ Clerk Date Permit Issued ST3 �� 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,CORyDS Inspection Date Findings(use code) Applicant Notified 1st 2nd 3rd 4th (To Permit Clerk) REMARKS CODE IB 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 APPLICATIONMERMIT FOR HIGHWAY_EXCAVATION'AND,REPAIR , 1. Permittee's Contractbrs fo'CorintrlvwitIrPernri(Rcauirciuen_ts The Permittee i5 responsible for ; inforifiihi itsiiadepcndentcontraicto=s;'employces;`agents'an, it signs oftheir responsibility to comply with this permit;,inoluding al spa;Ial/i`6,specifrc and general conditions imposed by the Highway Superintendent while acting as the"permitiee's agent with'rrspcct to the permitted activities,and such persons shall be required to comply with`all permit requirements: 2: No.Right to Trespass cin Inter"fere with Private l'ro»erty IUAts"t 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:t-authorize the tmpairine t"of tiny'rights,title,or interest in real or personal property'held or; vested.in a person not a'party to the permit, 1 Protection of t!i'e Iii hivay and Tuture Iliehwny Mnintcniince: If future operations,or,highway, maintenance-projects by the Town of Southold require air'altemtion in th'e position of the utility,structure or,wortc' herein cuthorized,or;ifJn die opinion of the Highi�iiy Superintendent the work perfo`rm'ed under this permit shat)cause unreasonable obstruction to required highway maintenance or endanger the health_; safety`and/or welfare of vehicutar or pedestrian tiaffic,this permit'shall be revoked and the':tility,- sinrCtuie,-flll,cXcavAtiori,;oi 6&r',modification'ofthe highway hereby-authorized shall not be.completed. Additionally,the permit may be rcvokcdif the Highway Supertntendent,firids that the issuance of the permit was*11' it orunauthorized`or'that the'applicairt fai{cd to comply with any, the terms and conditions of the permit,or Chapter 23Tof the Town Code. „ 4,- Reyocsrtiort-bf the Permit"bv the Iliehway Sumcriateriilent: If the Highway Superintendent deems it necessary to,revoke this permit°and ilia project hereby authorized has irotbeen completed,the applicant , `shAlovithoutexpense'to the Town and to such extent and in such time and manner as the Superintendent 'nay require,-remove ail orany portion of the"uncompleted utility,structure or fill and restore the site to its former condition. 5, -Notice'of Commencement: At least 206ars prior to commencement of the project,the permittee"and_/or cvntrac{or shall notify the Town.Higirway bepartment in writing that they are fully aware of and underst6nd.all terms and project conditions of this permit. Upon completion of the work,the contractor shall provide photographs of the Cori' work to the Town Highway Department an, ,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 in a rnAnner that does r of interfere with normal highway traffic. 7, Utility Marti-Orits: The Appiicarit/Contractor,shall be'responsible forverif cation of all existing utility' mark-tits;and shall take all precautions to.protect same. Damage to existing,utilities shall bathe responsibi4y 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 lark closures may be permitted with the approval of the'Highway Sup'erin'tendent. This item'will included but not be limited to the installation of appropriate signage:acid flag mento stop and start traffic to allow-for single lane traffic: Road Closures due to unforeseen -err`rergencles require immediate notification of the Highway Department and"shall be limited to immediate and?or expedited restoration'of the Work Zone,' . 9, No-Coristruction Debris in Road Shoulder.Area: All Construction Debris shall be removed from the job site;on_a daily-bass; All stockpiled'soll its well as all other project materials that will be staged within,the Rigli"f 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 1HGHWAY EXCAVATION AND REPAIR (Continued) 10. Install,Maintain Erosion Cdntrols: Required Erosion•Control Measures(i.e;.silt fe`ncing),is td,be placed ' on the downslope edge of any disturbed Brea. This sediment barrier is to be put in place before any , disturbatico,of the ground occurs and�is to lie maintained in good functional condition until thick vegetative cover is established. l i._Clean Till On lvi-,All project back-f Hi shall consist of clean sand,gravel or soil,(NOT asphalt,slag,flyash, bioken.eoncrete or demolition debris). All unsuitable soils'excavatcd at the site(i.e.;Clay,BOB;etc)are to, be removed from the site and'not used to_b 60,11 any excavation within aTown Highway. 12. Ali'Areas of Soil Disturbance All areas of soil,disturbance resulting from.ihc approved project shall be stabilized-to the satisfaction-of the Highway Superintendent immediately following project completion. If the,pro tci,site remains inactive for"more than 48 hours'or planting is impractical due to the season,then. the area slu li,be stabilized with straw,haypiulch and/or jute"matting until weather conditions favor ' germination. 13.`Bactcfill&-Com»netion of sill icicnvsitioits: ;Back Fill shall consist of clean fill or soils which exhibit a well-defined moisturiden"sity relationship is determined to be'in accordance with ASTIVID_698., Fill steal! bc`placed in maximum lifts of twelve(I,2') nch-sthick and shall be mechanically,compacted to a Ninety- foe(95%°}percept maximum dry density. Suitable hydrdulic compaction-by water jetting atthree-foot. ;intervals will Also be permitted subject io�a project specific s;pproval_tiy the Highway Superintendent. 14. Restoril{inn of rite Road Slso`utdcr A'rcii: Allman=nia, c improvements located within existing road shoulder a'reiiss must be'piotected to the'greatest extent pcacd6iil.''Items would include but not be limited io driveway&private road aprons;mailboxes,sprinkler systems,trees and ornamental plantings. Excavations through,driveways and private road pavements must be,reconstriicted toeet all "reqm uireents of Southold Towp Highway Specifications; All pre=existing road sho .m ulder irr pmo etnents tha#have been disturbed during construction must be replaced or repaired 6 the contractor to the satisfhdU6a ofthe Highway Superintendent. 15. Sclitimntic'Plans with affTechnical information and Scone of Work :To reasonably and adequately describe'the'propa"sed work;`accurate schematic site plpns must be provided to"show or indicate all proposed construction activity required under this permit. All Paveri�ent'surftices`scheduled,for excavation must be saw cut to the fall do th'of asphalt and/or concrete pavements. Accora4e„size of bell holes`or width of trenching'must be indicated by'd6clion or labeling. This schematic'site plan must provide details on all resf&ation required to irieetthe`requiretnents'ofthese General Conditions and regutretmnts found in the Southold Town Highway-Specifications, - 16. Pavement-Recons'truetion: All Pavement sections must be reconstructed in"the following manner, .(Note:When,Concrete Pavements are Present,Please review Restoration requirements with the Highway SuperWn rident) a) Complete all back-fill&'i6ff,c6mipa6tion work as,needed to provide a suitable sub-base; b) Over=cut eXisdilg asphalt bell hole or trench by ttvclvc(12")inches on all sides; . c) install a compacted rift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification); d) Install a two'and ane half(2.5") in1ch compacted lift of Asphalt Base Course;. C) Inne and one`half(1:5")`inch of Asphalt(Type 6)1Vearing Course. (Provide AC at.al!joints) All work,listed herein must meet`the minimum requirements of the Southold Town Highway . Specifications. ; 17. Trenching'of Pavement Surraces Exceeding One Ilundred(100'1Tcei in Lenath: All trenching of pavement surfaces exceeding loo' in length must,first be reconstructed to meet the resiuirements of Item H 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") inchlift Of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder): Pation- aa 00 a --MRMTr APFI-1CATION,SKETCH- Village,,Of u DATE: 111812017 �3 U L'OCATIOM, 1-625 INDIAN NECK L4moss STREET Iv SPRING-LN 3 - bA 'T,OWN: PECONIC CROSS'STREET 2: ,KIELBA'S;A ALY WORK ORDER.. T1:0,1922967 'd _ bA M �i - U d• .SURFACE:, Macadam,,Ro d,_j ;,'Hom Wal ,� cd � 1'625,' A a` i � o J •� bA �° cd cd 4;-x 4VI3e11'Hole- U U INDIAN NECK L4V - - � 3 * * * RECEIPT * * * Date: 01130/17 Receipt#: 216046 Quantity Transactions Reference Subtotal 1 Excavation Permits 1193 $17000 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#37005 $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. 1193