HomeMy WebLinkAbout3150 Boisseau Ave * * * RECEIPT * * *
Date: 02/03/17 Receipt#: 216205
Quantity Transactions Reference Subtotal
1 Excavation Permits 1196 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#37137 $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: LYNDAR Internal ID. 1196
RECEIVED
Permit No. FEB - 2 207
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT Pee
Peconic Lane Southold lbwn Clerk �..,
Peconic,New York 11958v
T101882972 (631)765-31401 ,
APPLICATION-f PRRMIT TOR HIGITWAY L:XCAVATION 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,Suffaik 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
1 516 545 4094 175 E. Old Country Rd Hicksville, NY 11801
Name of Applicant Phone Number Address of Applicant m
2. e
Name of Contractor Phone Number Address of Contractor '
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. 3150 BOISSEAU AVE-E/S, 210' S/0 YENNECOTT DR, SOUTHOLD
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
NOTE: All information requested by this Signature of Applicant
Application/Permit Form Is
,Required for a complete application! 1/27/17
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 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.
(e) 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 . SectionS . Block G , Lot i
7. Starting Date. 2/26/17 Completion Date: 2/27/17
8. Work Schedule: Phnse Completion 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 orProposed Work: $ —
11. Remarks: OPEN (1) 4'X4' MAC BELL HOLE TO REPAIR GAS LEAK
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 Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and$2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided in the total Amount of$
(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 520.00 S 20.00
No.
A2. /Additional Excavations same service(Qa $10.00 S
No.
B. Excavations IS"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 @$10.00 $
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:
n accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if ny) ached heret
SUPERINTE E S
TOWN OF S RK
Vincent o
r� t� Date
Date Received by the Town1Clerk_ �!' I
Date Permit Issued O( ' J-(a®t 1 Permit No. \ -1
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 24 hournotice to Superintendent of Highways.
Permit must be available at all times for inspection,on site,during construction,
D-39 2 of 3
Copy Distribution: 1 C1
Permit# �,,,
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
1 St
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
1B 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 Excavadon
RFR Ready for Repair
D-39 3 of 3
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
1. Permittee's Contractors to Comply with Permit Repuireanents: 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 specific and general conditions imposed by the Highway
Superintendent while acting as the permittee's agenf with respect to the permitted activities,and such
persons shall be required to comply ,ith-all permit requirements .-
2. No Richt to Trespass or Interfere with Private 1'r6»erty 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 nordoes 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 permit.
3. Pro'tcetion of tl�e Iliglsivav and Future Ilielnvny Mnintenance: If future operations or highway
maintenance projects'by the Town of Southold require an alteration in'thc 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 permit may be revoked if the Highway Superintendent finds that the issuance of the
perink 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 Highway Superintendent: If the Highway Superintendent deems it
necessary to revoke this permit apd 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 orany portion of the uncompleted utility,structure or till 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 are fully aware of and
understand all terms and project 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. Storaie of Equipment&Materials: The storage of construction equipment and/or materials shall be
confined within the project work aces and/or adjacent areas where permission/legal a6cC s'hats been
obtained iii a manner that does not interfere with normal highway traffic.
7, Utility Mark-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 existing utilities shall be the
responsibility of the contractor and shall be repaired at the contractor's expense.
S. Road Closures: All scheduled road closures must first receive written permission from the Southold Town
Board prior to closing it 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 traff c 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 Road Shoulder Area: All Construction Debris shall be removed from the job
site on a daily basis. All stockpiled'soil as well w 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
APPLICATIONMERMIT FOR HIGHWAY,EXCAVATION AND REPAIR
(Continued)
10. Install,Maintain Erosiori 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 or demolition debris). All unsuitable soils excavated at the site(i.e.Clay,Bog,etc)are to
be removed from the site and itbi used to backfill any excavation widtin 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 inimediaiely following project completion. If
the project site rorriaitis inactive for more 48 hours or planting is impractical due#o the season,then
the area shall be stabilized with strewhay'mulch arid/oi jute matting until weather conditions favor
germination.
13. Backfill&Compaction of all 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'�inches thick and shall be mechanically compacted to a Ninety-
five( 95%)percenttnaximum dry density. ' Suitable hydraulic compaction by water jetting atthrec-foot
intervals will also be permitted subject to a project speoifrc approval by the Highway Superintendent.
14. Restoration oNlic Road Sirouldei-Area: 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&private road aprons,mail boxes,sprinkler systems,trees and ornamental plantings.
Excavations th'rough,driveways and private road pavements must be reconstructed to meet all requirements
of Seuthold Town Highway Specifications, All pre-existing'road shoulder im'p'rovements that have been
disturbed during construction must be replaced or repaired by the contractor to the satisfaction of the
Highway Superintendent.
15.,Schematic Pians with all Technical information and Sco' a ofWork: 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. All Pavement surf Ices scheduled for excavation
must be saw cut to the full depth of diphalt and/or concrete pavements. Accurate siie of bell holes or width
of trenching must'be indicafed by dimension or labeling'. This schomatic 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 am'Pri sent,Please review Restoration requirements with the Highway Superintendent)
a) Complete all back-fill&so-if compaction work as needed to provide a suitable sub=base;
'b) Over-cut existing asphalt bell hole or trench by twelve(12")inches on all sides;
e) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification);
d) Install a two and one half(2.51 inch compacted lift of Asphalt Base Course;
c) 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 Pnvement Surfaces Exceedieg One hundred(100')Tcet in Length: All trenching of
pavement surfaces exceeding 100'in length must first be reconstructed to meet the requirements of Item
# 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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.,_..REQUEST-FOR-STREET OPENING-PERMIT..-._w..W.....-.._..,-_____.,...._.___.._.._.__
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❑ ® NASSAUSUFFOLK ®
Fw•sl 114 STATE COUNTY COUf�TY COUNTY
PERMIT
1Md0 JOB�`01 992.672—
®ATE ;L.1 I
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LOCATION3 �Q S flu VIC 4Z)D� s f PR. d 7'
REASON OPENING R G I 615 L17-,JgI<
W.OJPA FOREMAN DATE OF
NO. OPENING
REQUESTED DEPARTMENT. DIVISION
BY S. GAS CONSTR.MAINT.&SERVICES ,69S-176AAl cd FFOLK
APPROVED DATE
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