HomeMy WebLinkAboutYoungs Ave (2) r ,
* * * RECEIPT * * *
Date: 02/14/17 Receipt#: 216403
Quantity Transactions Reference Subtotal
1 Excavation Permits 1197 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#37310 $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
Bld 3 FI 1
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID. 1197
Permit No.
TOWN OF-SOUTHOLD �sulFll�r
H1GHVt7AY,DEPARTMENT
Peconic Lane & .
Peconic;New York 11958
T101827633 (631)765-31401
APPLICATION!PERMIT FOR,HIGIIWAY TXCAVATION AND Rr,,PA]R
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 or 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 witfi all applicable'laws,
ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit-aulhorized
inspectors to make necessary inspections of file job site.
Print or'1'vnc Keyspan Gas East Corp D/,B/A National Grid
Gas Permits Dept. Bldg: 3 FI: 1
l Lois J Griggs 516-545-4925 175 E. 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 nppiicable) Address of Owner
4. e/s Youngs Ave 65 ft n/o Town Creek Ln - 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.
Lois J Griggs
NOTE: All information requested by this Signature ofAppiicant
Application/Permit form Is
Required for a complete application: 2/10/17
Date
5. (a) Attached plot plan to reasonably and adequately describe the proposed work, Provide accurate schematic site plan showing the
locntion of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description or
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 Highway Excavation Permit by the Town Clerk.
6. Tax Map No: District 1000 . Section , Block . Lot
7. Starting Date: 2/10/17 Completion Date: 2/13/17
8. Work Schedule: Phnse Completion Date
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,tine Utility being modified.
10. Estimated Cost of Proposed Work: $
11. Remarks: open (1) 4 x 4 mac bell hole to repair gas leak
D-39 � 1 of 3
12. Insurance Coverage:(Attach Copy)
(a) Insurance Compdny:
(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 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.
AI. /Service Connections excavations Q 520,00 S 20
No.
A2, /Additional Excavations same service @ S 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;Additional L.F.®S0.30 S
D. Excavations 5'in depth and over
0-100 L.F.=$50.00;Additional L.F.Q$0.50 $
E. Utility Repair Excavations Q$10.00 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 Exca ation permit to:
accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if a )attached heret
SUPERINTEN G
TOWN OP SO K
i cen rla o
t-1 --- - -
Date
Date Received by the Town Clerk 01
Date Permit Issued eQ- I L4" I 1 Permit No. t 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(use code) Applicant Notified
1 Sl
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,P-tRMIT; .
APP"LICATIONMERMIT FORNHIGHWkY MCAVATION AND REPAIR
1. Pcrinii'tcc's Caittricfars io Conmly wiili'Permit Reauiresheti[s The Permittee is responsible far
irifarmiiig its ind"''d nt contractors,employees;"agents urid assigns of their responsibility to comply with
this,peimit,`mi lad"'all speciaUsite specific„and'genccal'cond tions imposed by the Highway
Su"perintendent while acting as the permitlee's asentwiih respect to tfic permitted'activities;and such
persons shall be iequired'to comply with`all permit requirements.
2, No Riehl io Tresnsss'or Interfere tivith°P#46(c Propei!jMetitsf This permit does not convey to the
permittee any right fq trespass upon ttie lands'of adjacent property"vwriers in order to,poff ffn the permitted
Awork fidr does 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. Protection of the Highway and Tuture Iiielrnyay'MMntcnancc: If future operations or.highway
maintenance projects by the Town of Southold requir`c an alteration-in the position of the'udlity,structure
or wartc'herein authorized,or if„in'theop pion of the Highway Superintendent the WA pertormed under
this permit shall cause unr`easonable'obsiivation to required highway,mainienanee or endanger the health,
safety and/or welfare of vehicular or pedestrian traffic,this permit shall be r',evoked acid the utility,
structure,fill,excavation,or other modif cation of the highway hereby,authorized shall not be completed.
Additionally,the permit-maybe revoked if the Highway Superintendent-finds that the issuance of the
permit was illegal or unauthorized'oi"th'at the applicant failed to comply with any of the taints and
conditions of the permit or Chapter 237 of the Town'Code.
4, Revociition of the Perniit,by the Highway Superintendent: If the Highway"Superintendent deems it
necessary"to revoke this permit and theproject hereby,petthorizedbas not been completed,the applicant
shit 1,without expense to the Town and to'such extent and in such time and manner as the Superintendent
may"reyuito"remove all orany portion of the uncompleted utility,structure or fill and restore the site to its
former condition."
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. Stoma of-Equipment&Moterinlst 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 i 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.
8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town
Board 'prior LO closing a road. Temporary lane closures maybe permitted with the approval oftl►c Highway
Superintendent. This item Will included but not be limited to the installation of appropriate signage and
flag men to stop and siari_traffic to allow for single Ione traffic. Road Closures due to unforeseen
emergencies require immediote�notification of the Highway Department and shall be limited to immediate
and/or expedited restoration-of the Work Zone,
q, Na Construction Debris in Road'Shoulder Area: All Construction Debris shall be removed from the job
site oria 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 means to meet the minimum requirements
of the NYS DOT'Construction Standards.
i -
{ RMI!'I'
GENERAL CONDITIONS OF�PI;
APPLiCATION/PERMIT.FOR',I-nGI WAY,EXCAVATION AND REPAIR
(Continued)•
1 Q, irisiall;,Maintain l;rosion'Con'tibls:-;Required Erosion Control Measures(i:e:silt fencing)js to be placed
on the do""wn"slope edge of ariy`disturbed area, This sediment batrieris to be put in place before any ,
disturbancii of the grouiid occurs and is to be mainitiitied in good functional condition until thick vegetative
cover is established.
11: Clean hill Only: All project back-fill shall consist of clean'sand,gravel or soil_(NOT asphalt,slag,flyash,
6ii keti'concrete or°demolition-debris). All unsuitable soils excavated it the site(i.e.Clay,Bog,etc.)are to
be removed fiam the site Mind not used to backfill any'excavation within a Town Highway.
12. All Areas of Soil Disturbiince: ,All'areas of soil disturbance resulting from the approved project she!l be
stabilized to the satisfactionof the Highway Superintendent inn nediaiely following project completipn:'If
the project site remains inactive forJriore than 48 hours or planting is Impractical dtie to the season,then
the'area'shall be stabilized with straw,hny.mWch'and/or jute matting until weather conditions favor
germination.
13. Bdc' kfill&Coninaction of nll l~xcavatioiis: Back Fill shall consist of clean fill'or soils which exhibit a
well=defined inaisfure density"'relitidin ip as deterinined_to be in Accordance with ASTMD 698.•Fill shall
be pIace d inmaximum-lifts of twelve(12')inches thick and,shall be mechantciilly coiitpicted to,a Ninety-
fvc(95'%a percent maximum-dry density: Suittible hydraulic compaction by water jetting attliree=foot
intervals will also be permitted subject to a project;speciftc approval by the Highway Superintendent,
14:Rester`atiohortheRoad�Shouldcr`Areit: Allman-inadcimprovementsJlocatedWithin existingyoad
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 omarricatal plantings.
Excavations through driveways and private road pavements must be reconsttvcted to meet all requirements
of Southold Town Highway.Specificutions, All pre-existing road shoulder improvements that have been
disturbed during construction must be_replaced or repaired by the contractor to the satisfaction of the
Highway Superintendent. .
15. Scltelnntic Plnns with all Technical infotyiiaiion and Seenc of Work: To reasonably and adequately
describet e propoised work,accurate scheriiatic site pians must be provided to show or indicateull
proposed construction activity required under this-perrnit.'All Pavement surfaces scheduled for excavation
mustbe' saw cut to the full depth of asphalt�andlor concrete pavements,. Accurate size of bell holes or width,
of trenching must be indicated by dimension or iabeling, This schematic 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 Paveiaents are Present.Please review Restoration requirements with the Highway Superintendent)
a) Complete all;back-fill&soil compaction work as needed to provide ti 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 Blend base(RCA Blend must meet NYS DOT Specification);
d) Install a two and one half-(2S")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 meettheminimum requirements.of the Southold Town Highway
Specifications.
17. Trenching=of Pavement Surfaces Exceedingr One hundred(1001)Fcct in Length: All trenching of
pavement surfaces exceeding 100' in terigth 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(Typo 6)Wearing'Course(Typical,shoulder to shoulder).
sJ ty
nationa-1 g0d,
F%gM-r APFUWjQ:X--S1KETCH
Village Of.
,'DATE: 2/1012017 W)
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ELIZABETH A.NEVILLE,MMC ` Gy Town Hall,53095 Main Road
TOWN CLERK %� PO. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS p ® .� Fax(631)765-6145
MARRIAGE OFFICER �� ®�' Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
APPLICATION
SINGLE AUTOMOBILE TRAILER OR HOUSE CAR
Fees:
250.00 (for maximum of six (6) months) Must be submitted with application.
7
_$100.00 (for maximum of 6 months) for trailer on land used in agricultural
production. (see attached, proof may be required) Fee must be submitted with
application.
Please check one:
New Application ( Renewal V Permit No.
Received Date:
Issue Date: Expiration Date:
Name of Applicant:
Mailing Address: f�
6 uU I
Telephone No. 3
Applicant is: ( ) Owner ( ) Lessee (VIAgent_for Owner ( )Agent for Lessee
Name of Owner of Premises
If owner is corporate, signature andtitleof duly aufhoriTs le office' r:
Cl VAC (����L`�
Number of Occupants & Names: yCLj-i'fS— oo Odel'n
MailingAddress
Telephone No.: r (-
Employer of Occupant F–(��� �,Q/f l�.1y� C�1(. jIfV1
(Name) (Address) (Telephone Number)
Property Information
Street address of land on which trailer will be located:
61q-7o
SCTM#: 6,' `
Permit will not be issued if the SCTM#is not provided
Existing use and occupancy of premises and intended 7sA7d occupancy of proposed trailer:
1. Existing use and occupancy Kj
2. Intended use and occupancy
3. Name& Title(s) Occu ants
(h In
( ) Owner I ( ) Other, indicate relationship
4. Period of time trailer is to be located on premises:
/ vf?az—
Lot Size: Front It 25- aoff% Rear Depth
Date of purchase or lease of land
Zoning District for premises:
Does proposed use violate any zoning ordinance or law? ( o ( )Yes
If yes, explain on separate paper.
Trailer Information:
Length qn-f Width U7 Height g
Registration No. Serial No.
Method of Sewerage disposal
Source of Water Supply
Source of Electricity
IMPORTANT
Copy of survey showing location of existing buildings and existing/proposed trailer must be
attached to this application.
State of New York
County of Suffolk _
'/p UAJO— being duly sworn, deposes
and says that that (s)he is the applicant named above and (s) he is authorized to make and
file this application; and that all statements contained in this application are.true to the
best of(her) his knowledge and belief; and that the trailer will be located in the manner set
forth in the application filed herewith.
C11
(Signature)
Sw-Qrn to before me this 13 day of
f-W , 20)
(Notary Publi )
SMANIEvBROM
,f4 tarry-Public,State of New Yqk
No.01 BR4908712
Qualified in Suffolk County �O
0arnmission Expires October 19,r�..
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