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HomeMy WebLinkAbout315 Fleetwood Rd (3) Permit No. TOWN OF SOUTHOLD �goFFoc,t�, HIGHWAY DEPARTMENT Peconic Labe Peconic,New York,11958 a ,� 7101798974 (631)765-3140 A-PPLiCATION/PERMIT FOR HIGIIWAY EXCAVATION AND RTPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town-or Southold for the issuance of an Excavation Permit pursuant to Chapter 239 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or regulations fo�,each individual contiguous ekcavation 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 makenecessary inspectio ns of the job site. Print or'I'vnc Keyspan Gas East Corp D/B/A National Grid Gas Permits`Dept. Bldg: 3 Fl: 1 f, 516 545 4094 175 E. Old_Country Rd"Hicksville, NY,11801 NameorApplicant 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. 315 FLEETWOOD RD-N/S,, 75' W/O HAMILTON AVE, CUTCHOGUE 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, 6�OUP NOTE: All information requested by this Signature of A licant Application/Permit Gorm is Required fora complete application! 1/26/17 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 givea detailed description of all site and payement restoration work. (b) Attach all other necessary permits and licenses ror this project (e) Work covered by this application may not commence before issuance ora Highway Excavation Permit by the Town Clerk. 6.- Tax Map No.: District 1000 . Section , Block , Lot 7. Starting Date: 2/25/17 Completion Date: 2/26/17 8. Work Scheduler Phase Cornnlction i3htc Excavation Wark Schedule Facility Installation f1'lust be provided Backfill S 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: ` S 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 M (c)State whether policy of certification on frie 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 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 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, I Additional Excavations same service a@ 510.00 S No. B. Excavations IS"in depth or less 0-100 L.F.=$10.00;Additional L.F.©$0.10 S C. Excavations 18"in depth to 5' in depth 0-100 L.F.=$30.00;Additional L.F.Q$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 S No. Repairs same service Q$5.00 5 Additional TOTALS 170.00 F. Notice to public utilities proof must be provided and Shall be attached to this application prior to issuance ofpermit. Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Exca tion permit to: _ n accordancevi this application and subject to the"General Conditions"and"Special Conditions"of permit(if ny) ttached here SUPERINTE E YS TOWN OF S E ORK Vincent M.Orlon Date Date Received by the Town Clerk Date Permit issued < 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 RECORDS Inspection Date Findings(use code) - Applicant Notified 1st 2nd 3rd 4th (To Permit Clerk) REMARKS CODE 1B Improper Barricades 1L Improper Lights ST Sunken Trench or Excavation , UTM Unable to Measure(due to backtilIing) 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;HIGHNVAY EXCAVATION AND REPAIR 1. Permittee'c Contractors to Comely with Permit Renuirenicnts: The Permittee is responsible for informing its-independent contractors,cmployees;,4gents and assigns of their responsibility to comply with thls;permit,"including all special%site specific and general conditions imposed by the Highway Superintendent while acting as the permittee's agent with respect to the permitted activities,and such persons shall be required'to comply with all permit;requirements. 2. No Right to Trespass or Interfere with Private Pronerty Rights: This permit does not convey to the perinitke 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 persoh nota'pariy to the permit.' 3. Protection of the Highway and Future Iiietnvay Maintenance= If future operations or highway riiaintenance projects by.the,Town-of Southold require an alteration in the position of the'utility,structure or work herein authorized,or if,,in dhe opinion of the Highway Superintendent the work persornied'under' this-permit_shill caiise unreasonable ob'structi'on to required highway'maintenance or endanger the health, safety;and/oh welfare of�vehicular or pedestrian traffic,this'permit shall be;revpked aril the utility, structure,fill;excavation,or other modification of the liigfiway hereby authorized shall not be completed. Additionally;the permit may be revoked if the Highway Superintendent finds tBatthe issuance of the- or'illegal or unarithbfized or that the applicant failed to comply with any of terms"and conditions of the permit or Chapter 237 of the Town Code, 4, Revocation'of the Permit by tlic lliehway Suiicrint6iidenti If the'M'ghway Superintendent deems it necessary to revoke'this pa=in=t and the project hereby authorized has no_t been completed,the applicant st=i=ll,without expense to the Town and to such extent and"in such time and mariner as the Superintendent n=ay require, all oral- portion of the uncompleted utility,structure or fill and'restore the site to its former condition: 5. Noticc 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 AM provide photographs of the completed work_to the Town Highway Department and request a Final inspection: 6. Storage of Enui6ment&Materials: The storage of construction equipment and/or materials shall be confined within the project woIrk'srea and/or'adjacent areas where-permission/legal access hies been' obtained in a manner that does not interfere with normal highway tMff c,. 7, Utility Mark-Outs:-The Applicant/Contractorshall be responsible for verification of nl1 existing utility mark-outs-and shall take all precautions t6 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 mustfirst receive%yritten 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 starttraffic 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 Constrnction'Dehris in Road Shoulder Area: A11 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 must be delineated With reflective signage or other mean's to meet the minimum requirements of the NYS DOT Construction Standards. GENERAL CONDITIONS OF PERMIT APPLICATION/PERAUT FOR I-IGHWAY EXCAVATION AND REPAIR (Continued) _ 10. Instntl,'Mnintnin Erosion Controls: Required-Erosion Control Measures(Le,silt fencing)is to be placed. on the downslope edge of any disturbed aica, 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 cove"*is established. 11.,Clean Till Only: All project back-fill_shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash, Broken;concrete or,'derrtolitioddebris). All unsuitable soils cxcavatcd at the site(i.e.Clay,Bog,etc.)are to be removed from the site and riot used to backftll'any excavation within a Town Highway: 12. All Areas of Soil(Disturbance:'All areas of soil disturbance resulting from the approved project shall be stabilized to the satisfaotion'of the Highway Superiniendent imtnediately,following'proJeet completion. If the proje'ct'site remains inactive for'mo_re than 48 hotirs or planting is impractical due to the'season,11icn the aces sha116e stabilized with straw,hay mulch and/or jute m_ atting until weather Conditions favor ge,rr Ination. 13:Backfill&Ctinihitctidn of ttll'Excavations: Back Fill shall consist of clean f 11 or soils which exhibit a well-defined moisture density relationship•as determined to be in accordan6c'with A_ STMD 698. Fill shall -be placed in maximum lifts of twelve(l2'�inches thick acid shall be mechanically compacted to s Ninety- five(95%)percent maximum dry density." Suitable hydraulic compaction by water jetting at three-foot intervals will also be permitted subject td,a project specific approval by the Highway Superintendent. 14,2estoration of the Road Shoulder Area: All man-made improvements located within existing road shoulderareas'must be'protected to the geatestextent practical. Items would include but not be limited to driveway&private road aprons,mail boxes,sprinkler systems,trees and ornamental plantings.- 'Excavations through driveways'and private road pavements must be,reconstr•ucted-t. ' trieet all requirements of Southold Town Highway Specifications, ie►11 pre-existing road shoulder improvements that have been disturbed during construction_ must be replaced or,'repaired by the contractor to the satisfaction ofthe Highway Superintendent. 15. Schematic Plnns with nil Technical information and Scotie of Work: To reasonably And adequately describe ilia proposed"work,accurate schematic site plans must be provided to show or indicate all proposed construction activityrequired under ibis permit. All Pavement'surfaces scheduled for excavation must be saw cut to the full depth of asphalt and/or_concrete pavements. Accurate size ofbell holes oc width of trenching must be indicafed by diii tinsion or labeling. This schematic'siteplan'm-ust provide details on all restoration required to meetthe requirements of these General Conditions and requirements found in the Southold Town Highway Specifications. 16: Pavement Reconstruction: All Pavement sections'roust be reconstructed in the following manner, (Note:When Conucte Pavetacnts-are Presse ent,Plea 'review Restoration requirements with the Highway Superint*ent) a) Complete all back=fill&soil 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; c) lnstall a compacted Iift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specifrcalion); d) Install a two acid"one half(2.5')inch compacted lift of Asphalt,Iiase Course; c) Install a one And one half(1.5".)'inch of Asphalt(Type 6)1Ve wing' 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 17undred t100'17,cc(in Length: All trenching of pavement surfaces exceeding 1001 in length must first be reconstructed to meet 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 length of trench shall be repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder). s)ty 24/01/2017 12 :52 (-UTC/GMT) National -Grid , page, 2 ' W-T Def Ai: ' 19C/111C�T c/1Q,QTRCC1'_A11CN1A1G 1'fc�MAiT NASSAU SUFFOLtK '. _' GAN • .®�—�------ FC 6111.4 STAT.E u, COUNTY- � .COUNTY, Isy; ,Sov. L PERMIT MIS,JOB.,� DATE 17 LOCATION, Hap'tl REASON FOR,OPENING' 3." LFII K FOREMAN;, „ DATE OF N0. OPENING ' REQUESTED =' p DEPARTMENT" DIVISION,, ; . BY,.-' - j"'2 ice'/` ` -GAS'CONSTR.MA1NT.&SERVICES �AS7'fR/�1� APPROVED DATE.' ' SKETCH ' , , , • , . , " FL 0,00 * * * RECEIPT * * * Date: 01/31/17 Receipt#: 216094 Quantity Transactions Reference Subtotal 1 Excavation Permits 1194 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#37094 $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: 1194