HomeMy WebLinkAbout3230 Boisseau Ave Permit_No. 11i 0 3 "
TOWN OF 11FF
HIGHWAY DEPARTM NT
Peconit:Lane
Peconic,New York-11958 c
T101943612 .(631)765-3140
APPLiCA'ClON/PF.RMIT•Ft1RIiIG1IWAY,TXCAVAT[gN AND RTPAiR
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,Suffolk County,New York,androther Applicable lows,ordinances or,
regulation's for`each individual contiguous excavatiaa project hcceIn"descr=i=ed. '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 or'I'yne Keyspan Gas East Corp D/B/A National Grid
- Gas Permits Dept. Bldg: 3`Fl: 1
1, 516 545 4094 175 E. Old Country Rd Hicksville, NY 11801
Name of Applicant Phone'Number Address of Applicant '
2.-
Name of Contractor PhonaNumber Address of Contractor
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner ;
4 3230 BOISSEAU AVE-W/S, 62' S/O YENNECOTT DR, ,
Work Description and Location(Street Number;Hamlet,Cross Street)-
(a) Is conswctian located within 75 feet of tidal wetlands4 *Yes No
*If yes,other Town permits may be required.
Margaret P_aglia _
NOTE: All information-requested by this Signature of App ant
ApplicAtlon_1 Permit Tarm Is• 3/20/17
Required for a complete applicatloul
Date "
e vo • Provide accurate schemic.site lan shawin 'the
5. (A) Attached plat plan to reasomobly and adequately dcscrhbe the propos d� rk. �,�. .p. g
location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of
nil 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 Cxcavation Permit by the Town'Clerk.
6. Tax Map No.: District 1000-. Section . Block , Lot
7. Starting Date: 4/18/17 Completion Date: 04/19/17
8. Work Schedule: LI In Completion Date
Excavation . Work Schedule
Cacility Installation Alust be provided
Backfill S Completion for consideration as a
Pavement Replacement. Complete,Application.
9. Under which authority is application being mad.: 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:
ll. Remarks: OPEN (1) 4'X4' MAC BELL HOLE TO REPAIR GAS VALVE TO SECURE-SHUT OFF
D-39 1 of 3
12. Insurance Coverage;(Attach Copy)
• (a) .EnsuranceCompany:,„ - -.' „ ,
{c)State whether policyof certification on file,with the HighwayDepartment:
(dj Covem e'requlred extended to the Town: '
Any Loss including Bodily injury,property;or commercial injury caused by orattributnble to the work performed:
51,000,000 per Occurrence and S 2,000,000,geneia1 aggregate.
(a)Surety Bond or Certified Check - provided In the total Amount of$^
(b)Maintenance Bond provided:Y 2 gents or 3 years:
14. Fees for Applications and permits:
Basi,c,Application Fee for Each Project Location -_ $150.00 .
A-Project 1.oC tlon'would incluile•each Bell Hole and/or-every'ron'd opening or excavation within any
5W Radius whether or not they may be inter=connec{ed 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 520,00 S 20.00
No.
A2, /Additional Excavations same service Q 510.00 , _ S
No.
B., Excavations 18.'in depth or less _
0-100 L.F:C,$10.00 ;Additional LF.&S0.10 S.
C. Excavations-1S"in depth to 5'in depth -
"0400L.F.=$30,00;Additional I::P.®50.30
D. Excavations S'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,@$5:00 $
Additional
TUTALS 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 it Highway Excavation rmii to:,-
in acc' '
this application and"subject id the"General Conditions"and"Special Conditions"of permit(if any) t -her
SUPERINTENDENT A
TOWN PF SOUTH 'fiV O
inct
ff LE`lL „ Date
Date Received lby.the Town Clerk
Date-Permit Issued �? ` �I 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:
Perniit#
Highway Department,
Engineer(with page 3) '
Applicant ' ; -
Toviwri Clerk(Original)
INSPECTOR'S RECORDS . , '
Inspection DuceFindings(use code)' Appllcaiit Notified
2nd '
Mrd
_ (To Permit Clerk)
REMARKS
CODE -
IB . _ Improper Barricades
IL, Improper Lights
ST Sunken Trenofi or Excavation
'UTM Unable to Measure(due io backfilling)
BUC Building Under Construction ;
WIP Work In Progress
DB improper 13uckfill(too high,not sufficient)
HFS Inspector Holding,for Final Settlement of Excavation
RFR' Ready for'Repair
D-39 I of 3
k GENERAL CONDITIONS-OF PERMIT.
APPLICATYUN/PERMIT-FOR HIGHWAY-EXCAVATION AND,,REPAIR
I: Pcrmiitec's Confrncto'rs io Coninlvwith'Perniit Rcauircriun[s: Tlie,Permittee is responsible far
infdrinh its itidepandent cootinctors,cmployees;'agents and'as5tgns of their responsibility to coiripiy with
this:perm%-,,ihtludi;%al(spec(al/site specific and general`oonditions,imposed bythe Highway
Superintendent while acting as,tlic permittce's agent:with respect to thipermitted activities,,and such;
persons shall be required to comply with all permit requirements. : t
2., No Rwlt to Tresnhss or Intcrfcrc.with Priv'k6 Proracrty°Rielits:',.Tbis permitdoes fiat convey to the
permittee any;right to trespnss'iipon,ttte lands of adjacentpr9per1y9wner5 in order,to-perforin the`permitted
work nor does rt authorize the impairment of any rights,title;`or interest m real or personal property'held or
vested in aperson nota party to the permit, _
-3.- Pr'otectian-of the IJialitvnr►nod Tutur`c Ilielri4ay'Maintenancc: `If future_operations or highway ,
maintenance projects by.the Town of Soulhbld-require'an nitcration in the"position`of the utility,structure
or War herein authorized,or`if,`in the opinion of the Highway Superintendent file work perforriicd under'
this permit shall caiise.unrcasonable obstruction-to'required highway maintenance or'endanger-the IicAlth;
safety an or'welfkd of'vehicular or'pedestrian to ,ic,'this`permit shalt bq;revoked siid,the utility,'
structure,,fill,cxcayatian;or other modification of the highway_h'ereby authorized shail'not be completed.
Additionally,the permtt_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 teriirs and
conditions of the permit or Chapter 237 of the Town Code,' _
4. , Revocation of Etre Pcriiiit by the 14iiebwav Superintendent::If the Highway Superintendent deems it
necessary to revoke'this'paiinit and the project hereby authorized has not been completed,ttie applicant
stial l,.wttEtout expense'to_the_'Town and to such extent and in such time and manner as the Superintendent
may requirejemove all orany poitio"n of the^uncompleted utility,structure or'fill itrid restore the site-to its
former condition.
5. Notice of Camnicncements At,least 24 hours prior to commencement of the project,the permittee and/or . '
contractor shall notify Elie Town'ii6h iiay Depaitment tri writing that theyare fully awairc of and
understand all terms and project,coddiiions,of this'periitit. Upon completion of the work,the'cantriictor
shall provide phofograptis of the completed work to the Town Highway Department and request a Final '
inspection: „
6. 'Storai=e df -hutment-&Matcrials: The storage of construction equipment and/or materials shall be
confined within the project°viwark;area and/or adjaccnt'areas who permission!legal access tilts been
obtained in it'iiianner that docs noiniirfire with normal highway traffic
7, Utilify Mnrlc-Outs: The Applicant!Contractor shall be responsible for vcrificat'ion of all existing utility
mark+=outs,and shall take all precautions to protect same. Damage ta:existing utilities shall be the
responsibility ofthe contractor�and shall ba repaired at the contractor's expense.
8.` Road_Closures: Ali scheduled roud,clasures must first receive written permission from the Southold Town
Board prior to closing a road. Temporary lane'closures maybe permitted with the approval of the Highway '
Superintendent. This item will included but not be limited to the,'mstatlation'of appropriate signage and
flagmen to slop and start Haff c to a1low:far single lane traffic. Road Closures'dtie to unforesCeti gencies,n;quire immediate notification-of the Highway Depaitrrient and shall-be limited to in
and/or expedited restoration'of the"'Work Zone. '
9. No Construction D6riiin Road Shoulder Area: All Construction Debris shall be removed from the job
sitc`an a daily basis; All stockpiledsoil`as well as all other'project materials that will be."singed 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.,
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERNUT FOR IiIGHWAY EXCAVATION AND REPAIR
(Continued)
10, Install;Maintain Erosion Contrals: Required Erosion Control Measures(i.e.silt fencing),is to be placed
on thb-downslope edge of any disturbed area. This sediment barrier is to be Out in place before any
disturbance of the ground occurs and is to be maintained in good functional condition until thick;vpgetntive
cover is established.'
11. Clean Till Only: All project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash,
Uroken concrete or`demolition debris): All unsuitable soils cxcavatcd at the site-(i.e.Clay,Bog;etc.)arc to
be removed from the si'tc and not used to backfill any excavation within a Town Highway.
12. All Areas of SoilDisturbance:.Ail'areas of soil disturbance resulting from the approved project shalt be -
stabilized to the stitisfactiosof the Highway SupetintendenE itiimediiitely following project completion. If
the project site remains inactive for more than 48 hours or'plani6- is impractical due to the season,then
the area shall be stabilized with-straw,liay mulch and/or jute matting until weather conditions,favor
germination.
13. Ildelcfill&"Coni action of nil Excavations: ;Back Fill'sha11 consist of clean fill or sails which exhibit a
wellklefned moisture density,relationship as'determined;tobe in accordance with ASTMI?698..Fill shall
be placed in maximum lifts of twelve :&)inches,thick and shall be meclinnically compacted to a Ninety=
percent;maximuni dry density.' Suitable hydraulic compaction by water jetting atthree-foot
inteivals,will also be permitted-subject to a project specific;approva)by the Highway Superintendent,
14:Resteymti6h of the Road Shoulder Arai: 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 8i private Toad aprons,mail boxes,sprinkler systems,trees and -ornamental plantings.
Excavations through driveways and private road pavements must be'reconstruoted to'meet all,requirements
of Southold Town Highway Specifications, All pre-existing Toad shoulder improvetrients that;have been
disturbed during construction must be replaced or repaired by the a contractor to the satisfaction of the
' Highway Superintendent. - - _
15. Scherithtic Plans with nil Technical information and Scoiic of Work: To reasonably and adequately
uditiie-the propaied work,accurate•schematic site plans must be provided to show or indicate nil
proposed constriction activity'required under this permit. Ali Pavement surfacesJschedulcdfor ezcava pon
must be'saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of bell holes or width
of trenching must be indicated by dimension'or labeling. This schdinatic site ple ' ust 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 Rec6ustrii-eti0in All Pavement sections must be reconstructed in the following manner;' '
(Note:When Concrete Pavements are Present,Please review Restoration requirements with the Highway Superintende_nt)
a) Complete all back-fill�&soil compaction work-as needed to provide it suitable sub-base;
b) Over-cut existing asphalt bell hale or tr'enoh by'twelve(12'i)inches on all sides,
C)-Install a compacted.Iift of 4"thick Stone Blend base(RCA Blend'must meet NYS DOT Specification};
d} Install a two and one Half(2.5"'),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 Pnvenic»t Surfaces Exceeding One Iilundred(1001Tect in LcMlt: All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
N 16 as noted above. Once all pavement reconstruction is completed to the satisfaction ofthe Highway
Superintendent,the entire road section and/or width of road over the entire length of trench shall be
repaved with a two(T)inch lift of Asphalt(Type fi)Wearing Course(Typical,shoulder to shoulder).
sl ty
1-4 r-
4-4nati +':ono
a ;PLI MTr AWVCATXO'X;-SKETCH; M
-Village.Of
DATE 31201201-7 �
�t
a�
LOCATICN-- 3'230 BOISSEAU.AVECRoss srREET-'I:, YENNECOTT DRcn
',TONM: 'SOUTHOLD -CItOsssrREET2: -LISA DR
°Wa M ORDER: T101'q4361.2
to
c�
SMAPE:t
,.Macadam:Ro dp-
< 3230, i
z,. W
- . W
C.'
oq
:62' .b
w
A!,x.4' Bell Hale, �
Cr"
BOISSEAU--AVE
- 3
* * * RECEIPT * * *
Date: 03/24/17 Receipt#: 217377
Quantity Transactions Reference Subtotal
1 Excavation Permits 1203 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#37629 $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: 1203