HomeMy WebLinkAbout2700 Hobart Rd * * * RECEIPT * * *
Date: 03/23/17 Receipt#: 217328
Quantity Transactions Reference Subtotal
1 Excavation Permits 1202 $17000
Total Paid: $170.00
Notes:
Payment Type Amqunt Paid By
CK#37605 $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: 1202
RECEIVED
Permit No. o�
TO'47N,OF SOUTHOLD MAR 2 1 2017 �"�gUFFOL'
HIGHWAY DEPAR'T'MENT
Peconic Lune
Southold Town Cler ,r
Peconic,New Yoik 11958
T101940008 (631)765-3140
APPLICATION/PERMIT FOR°HIGIIWAY.TXCAVATION AND RrsPA]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 Cade of the Town of Southold,Suffolk County,New York,and other applicable laws,ordintinces or
regulations for each'individual contiguous excavation project herein described, The applicant agrees to,comply with all appiicable'laws,
ordinances,codes-and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized
inspectors to make necessary irispections of the job site.
Print ar'iync Keyspan Gas East Corp D/B/A National Grid
Gas Permits Dept. Bldg:'3 FI: 1
I 516 545 4094 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 applicable) Address of Owner
4. 2700 HOBART RD-N/S, 195' E/O OLD SHIPYARD 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 maybe required.
Margaret PagliaPeqLt�
NOTE: All information requested by this Signature of AplAicant
Application/Permit Form Is
Required for a complete application! 3/16/17
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 1440 , Section (eBlock , Lot V
7. Starting Date: 4/14/17 Completion Date: 04/15/17
8. Work Schedule: Phase Completion Date
Vnrk Schedule
Excavation
Facility Installation Must be Oravided
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 P:
(c)State whether policy of certification on rile 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:
$1,000,000 per Occurrence and S 2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided in the total Amount of$
(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 numberbf Project Locations shall be subject to the approval of the Highway Superintendent.
Al. /Service Connections excavations Q S20.00 S 20.00
No.
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 50.10 $
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 Q$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 ofpermit.
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excav tion permit to:
accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if y) ached a a.
SUPERINTEN N OF W
TOWN OF S , •� K
inc r n
` Date
Date Received by the Town Clerk 2)\
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)
INSPIECTOR'S RE,CORIDS
Inspection Date Findings(use code) Applicant Notified
1 St
2nd
3rd
(To Permit Clerk)
REMARXS
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
GENERA -CONDrrioiys QFTERMrr',;.
'APPLICATION/PERMIT.FOR'HIGHVVAY-,]EXCAVATION,AND'REPAIR=
l; Pcr'rniitec's Contractors to ldbri4 ivii 1 Per'niit`Rnpairciaenisd The Permittee is rn'sponsible for
: irifo ming'its m epondent contracto'r`s;employees;agents'"and.assi is oftEieir rc5ponsibillty to'comply with
this'permit,'including all speCiA,sitcspecifc acid general`conditions imposed by the Highway
Superintendent while acting as the permitlee's;agent with respect to the permitted activities;and such
persons shall barequired to comply;witli all permit fequirentients. ;
2. No Richt to Tres`a"' or Inlerferc tiviill"Jyate I'roticrty'Riehts;",This permit does not convey to the
perinittec;any rig ht'to trespass upon the land'cif a-Jagent pfoperty owners in arctcr to perform rile permitted
work nor does it authorize'the iiripairment'of any rights,,fitle,or interest is real or persona)property held or
vested.in a person'not a party to the permit.- _
3, Protection of the Ilialnvay and Tuture ITiglnvav`.l4'Iaintenance:,df future operations or highway
.. -. .�,-
maintchance pr'gj&J s'by the Town of Southold require en nitcration in the position of the utility,structure
or;work herein autl%rized;'or if,,in the optmon of the Highway,Superintendent the work perlbrmed under
this permit shall`ciuse unreasonable obstruction to tcqu�red highway maintenance lir endangerahe health,
safety and/ot•welfare of vehicular oc,pedestrian traffio;this pefth shall be:revoked and the utility,
structure,'fill;eiccavatioit;or rattier modif cation of the highway hereby aut}igrized,shall not be completed.
Additionally,the permit may be:evokod if the Highway Superintendent finds thatth, issuance-of'the _
permit was_illegal or,unauthoriied ortthat the applicant failed to comply with any of the teritis=and _
conditions of_&permit orChapter 237 of the Town Code.
4. Revacntion oldie Permit by the Highway Suoerinteiident: If the Highway,Superintendent deems it
necessary'to revoke this permit and the project hereby authorized Minot been completed,the applicant
Aiill,without'expense to the Town and to such extent and,in such time and iiianner as the Superintendent
may'requ'ire,�remove all orany portion of the uncompleted utility,structure or fill and restore the site to its
fernier condition:
5: Notice of Commencement: At least 24 hours prior to commencement of the project,the permittee and/or
contractor shall notifithe Town Highway Department in writing that they are fully'aware of Arid
unders#'and all terms and project conditions of flus Permit. Upon completion of the,work,the contractor
shill'provide photographs of the completed work to the Town Highway Department and request a"Final
inspection.
6. Storai=e 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'n manner that lines not-interfere witli.norm"I highway-traffic.
7 Utility ible for verification of all existing utility
mark outs and shall take all precautions to protect same,'Damage to existing utilities shall be the
respansibifity 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
13aard prior to closing a road. T=0t
lane closures may be permitted with the approval of the Highway
Superintendent. This item will not be limited to the installation of appropriate signage and
flag tiiento stop and start traffic to,allow�for single lane traffic: Road"Clospres.due to unforeseen
emergencies require immediate notificniion of the Highway Department and shall be limited to immediate
and/or expedited restoration of the Work Zone,'
9, No CoinstructionDebris in Rand Shoulder Area: All Construction Debris shall be removed from the job
site on a"daily basis; Al!stockpiled soll�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 6fistruciion•Standards.
-GENERA L CONDITIONS'0YPERMIT,,
APPLICATIONMERMI1r,*OkHIGHWAY,EXCAVATION,SID_REPAIR-
"; (Coritinucd)'
l Q,-InsLiIl"mitwoin Erosion Cont'roii" Regpired-Erosion'Control Measures'(Le'.silt fencing)is to be placed
on'thc downslope edge of iiiiy'disturb'ed area:,This sediment barrier is to be put io,pI iad before ariy.
distt�ibancc of the grnurid'occurs`o'lid is to 66,maintained'in good functionaLconditibii'utifitthlck vegemtive
cover is established.' _
I
'Cl iiiibiily:-Ait Project back-fill shall consist of clean sand,gravel oc'soif(NOT asphalt,slag;-flyash;
Eirokcn cancreta oi•'deinoliiion debris).`All unsuitable soils excavated at the"site{i;e.`Clay;'Bag;etc:)are"to.
ii.
removed from the site and"not use
to.i ckfill'any excavation within a Town Highway..
12. Alt Areas bf Soil 1Disttieliance� .All,areii of soil disturbahce'resuiting fro'm'the approved project shall be, -
p..
s bilized to the satisfaciion'oi'theHighway Superintendent immediately'following otoj t co''tii,01666n. 'If
_ .: -
theyproject stte'remaitis inactive for rnoie_than'48 hours or•plant4ng is'inipractical due to file season,then
the area shall be'statiilized with`straw,hay mulch and/or jute matting'until'weather conditions favor.
germination. ,
13. Iiaclttill a Coiupactron of ill Eacnvatidns: •Back Fill shall consist of clean,fill or soils which exhibit a ;
will=defined moisture densityfelitiorishi-pas determined to_be in_4ic 6idancc;with ASTivID 698. Fill shall
be placed in maximum.liflJof twelve(12')inches ihi6k,411d_Aillbe meohanically`cdmpacted to Ninety-
fvc,:(95%°)pe`rcent'maxitriurn dry;dcn5ity. Suitable hydraulic compaction.by water jetting a'ttliree=foot
intervals will also be periniE#edaubject to n,project specific approval by ilia Highway Superintendent,
14. Restor�stioii of.thc Rdad Sliouldcr Arcri All maxi-made lniprovcinents located within existing road
,,• , a--'i,�
shoulder areas must be protected_to the greatest extent practical. Items would include but not be limited to
drivewity&'private road aprosis,;inail6oXessprinklcr systetiis,frees and ornamental plantings;
Excavations through driveways and private road-pavements must be reconstnicted to meet all requirements
of Southold Town HighwayvSpecifications,.ali pre-existing road shoulder improve''tnents that have been
disturbed during const`ructio'n must lie replaced or repaired by-the contractor to the§ati`sfactign oftle
Highway Superintendent-.'-
Is
ent.'- '
l5. SchematicPlnns with all Technical information and Scone of Work: To reasondbly and adequately.
'describe the p'ro'posed work;'accurate"schetriaticsite_plans must be provided to'sht%w ar indicate all
-proposed construction acktyrequired under`tliis permit. All Pavement_surfaces scheduled for excavation
must be saw'cut to'the f ill;depth of asphalt and/or concrete pavements.,Accurate size`of,tiel!holes or width
of trenching must,be indicated by dimension or fabcling. This schematic site plari must provide details on
all re'sto'ration requirea,fa meet the requir`ernents ofthese 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 aro Prcaeet.Ptcase review Restoration rcyu9remeats with the Highway Superintendent) ,
a),,Coinplete all back-fill'&soil con'ipaction work its needed to provide a suitable sub-base;
b) Ove-r`--cut existing asphalt bell hole or trench by twelve(12")'inoties on"all sides;
c),In, a compacted lift of A"thick Stone Btend base(RCA Blend must meet NYS DOT'Specification};
-d) Install a two-and otie'lialf(2:5',')in compacted lift of Asphalt Base Course;
c), Install a one and one half(I3")inch of Asphalt(Type 6)Wearing Course. (Provide AC at all joints)
All work listed hcrein`must mcet the minimum requirements of the Southold Town Righway
Specifications. =
17. Tren'cliine_ ofPaventeitt Surfiiees Txceetlfne-One 1Tundred(l00')Tcetin Lenetlt: All trenching of
pavement surfaces exceeding 100' in length must fest be reconsiW6ted to meet the requirements bf Item
#"l6 as noted above. Once all pavement-reconstruction is completed to the satisfaction of the Highway
Superintendent,tiie 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;.shouldeato shoulder),
sl iy
Road Opening Permit Request nationalgrid
THEPOWEROFACRON
Municipality: Work Order:
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Location: Grid:
02700 �6Qr2T /0�/�--�5'gl�o,
Town: Requested By:
Reason For Excavation:
Description:
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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: