HomeMy WebLinkAbout120 Latham St Permit No.
TOWN OF,SOUTHOLD
HIGHWAY DEPARTMENT
Pcconic Lane
Pecotiic,-New York 11958 0 •
T101914-754 (631)765-3140
_ - APPLICATION/PERMIT FOR HIGInVAY TXCAVATION AND REPAIR
APPLICATION IS HEREBY made'to the Superintendent of Highways orthe Toiva of Southold for the issuance of an Excavation P&rnit
pursuarit to Chaptci237,07 the Codc of the,Town of Southold,Sufroik County,'Nc�v Vork,and other applicable laws,ordinances " , `
regulations for.cach individual contiguous'ckci vatian project herein'dcseribed, 'The applicant'agtees to comply avith,all applicable lava,
ordinances,codes and,,regulations,the aitached"Gettcral Conditions ofPermii'and"Special Conditions`, fany and to permit authorized
inspectors to make necessary inspections,af the job site:
Print or'['vnc Keyspan Gas East Corp.D/B/A National Grid
'Gas-Permits Dipt.�tidg:l-Fl: 1
1, 516 545 4094- 175 i=..Old,Ctiyrltry Rd Hick'svilte; NY 118.01,,.
Name,of Applicant ` Phone Number Address of Applicant
.2, _
NamcofContractor PhoneNumbcr_ Address,ofContractor
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. 120 LAT-HAM ST, ORIENT POINT
Work Description and Location(Street Number,Hamlet,Cross Street)
(a) is construction located within 75 feet of tidal wetlands? *-Yes- 'No
*If yes,other Townpermits may be'requked:
Margaret Paglia -
NOTE: All information requested by this - Signature,ofA iicant
Application 1 Pcrinit Form is =
-Required for a complete applicatlonl :1/19/17 =
Date
-5. (a)"Attached plot plan to reasonably and ade4untely describe the proposed work. Provide'accurate schematic site plan;showing the
lochadh of all proposed excavafions and rein,066hip to a`djoinin'g 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 ihis:appllciition may not commence before issuance ora Highway'Excavation Permit by the Town Cie&
6. Tax Map No:: District, 1000 , Section . Block: , Lot
2/18/172/19/17
7. Starting Date: Completion,Date.- ;
8. Work Schedule:- Plsnse Camnlctii►n[3;rtc
Excavation Work Schedule
Facility Installation Aust be&pvided
Backfill&Completion for consideration as a
PavementReplacement 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 nuthority`from,the Utility being modified:
10. Estimated Cost orProposed Work: S _
11. Remarks: OPEN(2)4'X4'GRASS BELL HOLES AND(1) 1''X 125'X 3'GRASS TRENCH TO INSTALL GAS MAIN&SERVICE
D-39 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
own:__,Any Lo`ss`inciuding Bodily injuy,property or commercial injury caused by or attributable to the work performed:
$1;000,000 pet Occurrence and S 2,000,000 general aggregate.
13. Security: `
(a)Surety Bond or Certified Check provided in the total,Amount of$
(b)Maintenance Bond provided:` 2 years or 3 years.
14._Fees for Applications and permits: _ J `
Bnsic'Application Fee for-Each Project Location - J� $150,00 3
A Project Locution'would include each Bell Hole andtor every road opening'or excavation within any
50'Radius`whither or not they may be iritee-connected by open trench or directional boring.
The total numper`of Project Locations shall be subject to the approval"of the Highway Superintendent.
Al. 2 /Service Connections excavations Q x20.00 g 40.00
A2. �- /Additional Excavations same service Q$10.00 S,
No:
B. Excavations 18"in depth or less
0-100 L.F.=$10.00;Additional, = L.F.Q$0.10 $
C. Excavations 18"in depth to 5'in depth
0-100 L.F.=$30.00;Additional' 125' - L.F.®$0.30 S,37.50
'D. Excavations 5'in,depth and over
0-100 L.F.=$50,00;Additional L.F.®$0.50 $ ,.
-E: Utility Repair Excavations Q$10.00 $
No.
„Repairs same service Q$5.00 $
Additional
'TOTALS 377.50
F:- Notice to public'utilities proof must be provided and ,
Shall be attached to this application prior to issoance of permit.
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:-
I accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit,(if a )Attache ret
SUPERINTEN S
TOWN OF SO Cti RK
)once .Orlan
Date
Date Received by the Town Clerk
Date Permit Issued I�o`,[�. Permit No. (. 1
NOTE:' Permit expires.one(I)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,onsite,during construction,
D-39 2 of 3
Copy Distribution:
Permit# _
Highway Depurtnient - - _
Engineer(with,pngc 3)
Applicant
Town Clerk-(Original) . ;
INSPECTOR'S RECORDS
Inspection Date Findings(use code) ,' Applicant Notified
1st
2nd
aid
4"
(To Permit Clerk)
CODE
IB -- Improper Barricades
1L Improper Lights
ST ,Sunken'french or lxeavafion
UTM W616 to Measure(due to backfill'ing)
BUC Building Under Construction
VIP Work In Progress
DB Improper Backfill(too high,not sufficiefit)
HFS Inspector Holding for Final Settlement"of Excavation
M Ready for Repair
D-39 . 3 of 3
GENERAL CONDITIONS-Or,PEI RAUT
APPLICATIONIPERMIT FOR RIGHWAY EXCAVATION AND,ItEPAIR,' `
L Renuirements: The Permittee is,responsible for
informing its iri8epbnderit contractors,employees,:agents and-assign`s of their responsibilitiy to comply with
this permit,°-including al(speciaUsitespecificond gencral'conditioris imposed by the Highway
Superintendent while acting ns the permiitee's°agent with respect to the permitted activities,and such
persons shrill be requ(r'ed to'compiy with all permit requirements.
2. No Ri"'ht io Tres ass or inierfe'rc with Piiv'nte Pro erftRi his: This permit does not convey to the
permittee any:right to trespass upon the lands of adjacent property owners'in order to;perfornm the permitted'
work nor does it authorize the impairment of any rights;titlg,'orinterest in;real ar personal property-held or
vested in a;per'son nota party to the permit,
3. Profecttan of the Iiighi��hy erid Tutarc IlieliwaY Mnintenancei:11`future operations or highway
inamtenance projects 1iy the.Town'of Southold require an alteration in the position of the utility,structure
or work herein authorized;or if,inthe opinion of the Highway Superintendcn't the work'' i rmed 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'rev6ked and the utility,
structure,fill,`excavation,or other modification of the highway hereby authorized shall not be completed.
Additionally,the'permif 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
condkions:of the:b"it or Chapiar 231 of the-To" 'Code'."
Code:°
4r -Reyocsitioa orihe Permit by(lie Hiehway Suncr"intcii nt:-If the Highway Superintendent deems it -
riecessary to revoke this permtt and t}ie project hereby authorized has hot,
con►pleted,the applicant
shall,without expense-tothe Town and to such,exfcnt ind,in such time and manner'us'ihe Superintendent
may,r`cquire,remove all orany portion of the uncompleted uq ity,,structure or fill and restore the site to its
former condition.
5. Notice of toniinihecment: At least 24 hoursprior to commencement of the project,the permittee and/0-t
contractor'shall notify the Town Highway Department in writing thatthey are fully aware of and
understand all terms and project conditions of this permit.-Upon compiedon of the work,the contractor ,
shall provide photographs of the completed work to the Town Highway-Department and request a Final'
Photo-
16, Storaee of'Equipment&Materinls: The storage of construction equipment and/or materials shall be
confined within-the project work area'and/or Adjacent areas Where permission/legal access hies been
obtained(n`a manner that does not interfere with normal highway traffic.
7, Utiiiil,N[Mc-Outs: The-Applicant/Contractor shall be responsible for verification of all existing'utility
mark=outs and shall take All precautions to protect same. Damage to'ext ing utilities shall be the
responsibility of the contractor and shall be repaired at the'coritractorIs 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 with the approval'of the Highway
Superintendent. This item included but not be limited to"theistallad6dof appropriate signage and
flag mento stop and start traff c,to allow for single lent traffic. Road Closures due to unforeseen
em'e'rgencies 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 tri 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 mU-isi be delineated with reflective signage or other meansto meet the minimum requirements
of the NYS DOT Construction Standards:
GENERAL,CONDITIONSOF"PERMI'I' -
APPLICATION/PERMIT FORI1IGHWAY EXCAVATION AND REPAIR
l0.•Install;Maiiioin Erasion Canirals:•Required Erosion Control Mepsares(i;e:silt,fenoing)is to be placed
an.ihe downslope edge of any,disturbed area. This sediment barrier is to Ere,put in place before any
disttirbaiicc;af the.ground occursand is to be maintained in good functional condition until thick vegetative 4.
cover is established: .
Clean-Fill Only: All project back-fill shall consist of clean sand,gravel'or soil(NOT asphalt,slag,flyash,
ken concrete or`derriblition debris), All u4ihible soils-excavated at the site(i.e.Clay;Bog;etc)are't
be removed from the site and not used"to`backfill any excavation wit hin't Town Highway:
l2. ,Alt Areas.of SoIIm ttir6arice All areas of soil disturbance resulting from the approved project shall be
stabilized to the`satisfaction of the Highway Superintendent itihrnediately following projcat completion.
If
the project_site remains inactive for more than,48 hoy'rs`or`planting i§impractical due#o.the season,then
tli6 area shall be'stabilized with�straw,he
mulch and/or jute matting until weather conditions favor "
germination.
13.;RaekGll&Coninnction of fill Ennvations 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', ifts oftw6N6(i2'�inches thick olid shall be mechanically compacted to aNinety=
fve percent titaximurri drj!densiiy. Suitttbl6 hydraulic eoinpaction by wafer jet#ing itttltree=foot'
intervals Will also be permitted�seibject to a project speclfc approval by the Highway'Superintenclent.
'
M,Restoration af'tlhc"Road S6i 1der Areal: All man-made improycments located within existingr`oad
shoulder areas must be•protected to the'greatestei tpni practical. Items would,`include but'not be limited to
drlveviray&
private road aprop5,mail boxes,sprinkler systems,trees and omanicntai plantings.
Excavations through driveways and private road pavements must be reconstructed to meet all requirements
of,SauiholdTown Highway Specifications,•All pre-existing road shoulder improvements ihafhave"been
disturbed ducirig construction must be replaced or r`eptiired by the contractor to the satisfaction of the
HighwaySuperintendent. -, - - _ - •
15. Schenintic'Plans with all Teehiiical information find Seonc of,Waili: To reasonably and adequately
describe the,propased io&k`acc'urattd's`chtfiii tic-site pians mustbe pravidea to show or indicate'all
proposed construction activity required under this permit. Ali PavemenYsurfaces scheduled far excavation
must be saw.cut to the full depth of asphalt a. I .r concrete pavements, "Accurate'size of bell holes or width
of trenching must be indicated by'dimension or labeling. This schematic,site planymust provide details on
all restoration required to mettthe requiretncnts ofthese General Conditions and requirements found'in the ,,
Southold Town Highway Specifications.
16. Pu' irrteat Reconstruction: All Pavement sections roust be reconstructed in the following manner;
(Note:When Concrete Paveiitents ora Present,Please review Restoration requirements with"the Highway Superintendent)
a);Complele all back=fill&_'soil compaction work its`needed to provide a suitable sub-base;
b) Over-cut existing asphaltbell hole ortrerieii by twelve(121')inches on all sides;
c) Install a compacted lift of Q"thick Stone Blend base'(RCA Blend must meet NYS DOT Specification); .
d) Install a two and one,half(23'!)inch compacted lift of Asphalf:Base Course;-
c)
Install,a one and orie'.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 TownMghway
Specifications.
17: Trenching of Pavement Surfaces Ei xceeding One hundred(1001)Tcet in Lengili 'All trenching of,
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
16 as'noiee above. Once all pavement'reconstruction is completed to the satisfaction;of th0 Highway
Superintendent,the entiro�road section and/or width of road over the entire length of trench shall be
,repaved with ti two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder).
sl iy
Road ®p enn ng Fermin Request nationalgrid
THE POWER OF ACTION
Municipality: �l Work Order:
&MI 01 �ou o�d 09 M 75iL
Location: Grid:
i,'?P LA;&Z ss!'
Town: Requested By:
aRr��t% e 6--//W
Reason For Excavation: 1i�/'zz
Description: oZ' 4k 4')e Y A�C A, ✓ ,r V A /X/aSX 3 -Y.r 4,,4A-rr
J,0' 5/o L.A,ds 0 Rel
4 l
Z ,fit
r
Typical trench width is 12"wide Not To Scale
Typical bell hole excavation is 4'x 4'x 4' Revision:
Permit sketch may not include excavations required under 16 NYCRR Part 753 Date Submitted:
* * * RECEIPT * * *
Date: 01/30/17 Receipt#: 216045
Quantity Transactions Reference Subtotal
1 Excavation Permits 1192 $37750
Total Paid: $377.50
Notes:
Payment Type Amount Paid By
CK#37006 $377.50 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 1192