HomeMy WebLinkAbout6500 4th St Perrrtit No. �� =
TOWN,OF SOUTHOLD o�suFFOc,��o
HIGHWAY-DEPARTMENT
Peconic Lane
Peconic,New York 11958 0'•
T101939013 _ (631)765-3140
APPLICATION/PERMIT rOR HiG11WAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY mode to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit
pursuant io'ClMpter237 of the Code,of the Town of 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 with all applicable lawa,
ordinances,codes and regulations,-the attached"General Conditions of Permh"and"Special Conditions",if any and to permit authorized
inspectors to make necessary inspections of the job site.
Print or'I'vnc Keyspan Gas East Corp D/B/A National Grid
das,Permi�ts Dept. Bldg: 3.FI: 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 PhoneNumber Address of Contractor
3,
Name of Property Owner Requesting Service(if applicable) Address of Owner -
4 6500 5th ST aka NEW SUFFOLK RD-W/S,•1.53' S/O GEORGE-RD
Work Description and Location(Street Number,Hamlet,Cross Street)
(a)-is Construction located within,75 feet of tidal wetlands? #Yes No
Nf yes ,other Town permits may be required. ,
Margaret Paglia
NOTE: All information"requested by this Signature of App' ant
Applicatlon l Permit roma Is
Required for a complete application) 31/21/17
Date
5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurateschematic site-plan showing the
location of all proposed ezcavatioris and relationship to adjoining premises,public streets`or areas,and give a detailed description of
nil site andpavement restoration work.
(6) Attach all other necessary permits and licenses for this project.
(e) Work covered by this application may not commence before issuance orn Highway Excavation Permit by the Town Clerk.
6. Tax Map No.: District_1000 . Section . Block , Lot
7. Starting Date: ., 4/19/17 Completion Date: 04/20/1,7 .
8. Work Schedule: Plimc 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 modirred.
10. Estimated Cost of proposed Work: S _ "
11. Remarks: OPEN (1) 4'X4'X2' GRASS BELL HOLE-TO UPGRADE & RELOCATE A GAS SERVICE
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D-3§' 1 of 3
12. Insurance Coverage:(Attach Copy)
(a) Insurance Company:
(b) Policy ti:
(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$2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided In the total Amount of$
(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$20.00 $ 20.00
No.
A2. I Additional Excavations some service @$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.Q 50.30 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 ofpermIL
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if y) ached he to
SUPERINTEN F S
TOWN OF S ti RK
in an o
'31n-1 l� ate
Date Received by the Town Clerk o.-- �
Date Permit Issued 3(D-1l(� PermitNo.
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)
RE1Y
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 PERMIT
APPLICATIONMERMIT FOR HIGHWAY,EXCAVATION AND REPAIR
1, Perinitlee'c Contractors 1o•Coinnly with Permit Reariiraftien[s:-The Permittee is responsible for . -
informing its independent contractors,ctriployees,agents and assigns of their responsibility to comply with
{his permit, lnelading all speciaUsite specific and'general conditions imposed by the Highway
Superintendent while acting'as the"permittee's agent with respect to'thc permitted activides,and such
persons shallbe required to co�riply with'all permit requirements:-
2, No Richt to Tresnasi'or Inicefe rc with piivRte llronerlj Rights: This permit docs not convey to the
permittee any right to trespass upon th' lands-of adjacent property owners in order to parform the permitted
work nor does'it authorize the iinpeirnent 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 M I�Iiwiiiv and Tuturc Iii liwsiv Mnintenaace. If future operations or highway ,
maintenance projects'by,the.Town of Southold require an alteration in` ' positioI n of the utility,structure
-orIwork,herein authorized,or if,in the opinion of the Highway Superintendent the work performed under
p
this permit shall cause unreasonable obstruction to required highway maintenance`or`endariger_the health,
safety and/or`welfare of vehicular or`pedestrian traffic;this permit shall be"revoked and the utility,
structure,fill,'cxcavatioa,or other modification of the higliwaj►,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 uni uthorized or that the applieant failed to comply with any of the terms and
cc ions lhe`Aermit or Chapter 237 of the Town Code.
4, Reyocs►ti6n of the Permit by the Hiebwnv Superintendent:If the Highway Superintendent deems-it
necessary to,revoke this permit and tkproject hereby iiuthorized hits 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 fill and restore the site to its
former condition.
5. Notice of Commencement: At least 24 hours prior to cbmmgncement of the project,the permittee and/or
eontiiidbr shall idtify'the Town Highway Department in writing that they are fully aware of and
understand all terms and project conditions-of this petTriit. 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. , Stora,a of r ui nient Sc Materials: The storage ofconstruction equipment and/or materials shall be
confined within the,project' ork'area andlor'adjacentore
as where permission/legal'access has been
obtained in a manner that does not interfere with normal highway traff c.
7, Utility Mnrh-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 to closing a road: Temporary lane closures inay`be permitted with the approval of the Highway
Superintendent.''This item will included but not be limited to the installationof appropriate signage and
flag tnen to—lop and Stasi traffic 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,restorationofthe Vork Zone,
9. No Construction Debris in Rand Should&Area: All 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 means to meet the minimum requirements
of the NYS DOT Construction Standards.
GENERALIONI)MONS OF PERMIT
APP`LICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
(Continued)
10. Install,-Maintain Erosion Controls: Required Erosion Control Measures,(i.e.silt fencing)is to b'e 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 functions!condition until thick vegetative
cover,is established.
11. Clean Till Only: All project,. -f*11 shall consist of clean sand,gravel or soil(NOT asphalt,slag',flyash,
broken concrete o�'demoliilon debris). Ali unsuitable soils excavated at•the site(i.e.Clay,Bog,,etc)arc to
b*e removed from the site and not tised to backfill any excavation witirin a Town'Highway.
.12. All Arens bf Soi!Disturbance:.Al!areas of soil disturbance resulting from the approved project shall be
stabilized to the•satisl'action of the Highway Superintendent inimedidLcly;fbllowing'project completion. If
the project site rerrtiains'inactive for more than,48 houis or planting is impracticaldue to the season;then
the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions''favor
germination.
13. mictiryi B:Corn z ction of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a
well-defined moisture density relationship as determined to ba in accordance with ASTMD 698. ,Fill shall
be placed in maximum lifts of twelve(12'1 inches thick and_shall be mechanically compacted to a Ninety-
five(95%a)percent maximum dry density. Suitable'hy�raulic compaction by water jetting atthree-foot'
intervals will also be pertrritted subject to'a project specific approval by the Highway Superintendent,
14. Restoration of thc'Road Shoulder Area: All man-made improvements located within existing road
shoulder areas must lie protected to the'greatest extentpractical.' hems would include but not b,limited to
driveway&private road aprons,mail boxes,sprinkler systems,trees and orriFttiiental plantings:
Excuvapons-th"rotigh driveways_and private road pavements must-be reconstructed'to fncetall requirements,
of Squtltolcl Town Highway Specifications, All pre-existing i6ad shoulder improyeMpnts that have been
disturbed during construction must be replaced or repaired bj►the contractor to the satisfaction of the
Highway Superintendent.
15. Schentntic Plans with nil Technical information and Scene of Work:-;To reasonably and;adequately
describe the proposed work;accurate schematic site plans must be provided to show o'r,indicate ail
proposed constivction activity,required under this it. All'Pavementsit r111 faces scheduled for excavation
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'diiitcnsion or labeling. This schematic,site plan must provide details an
all restoration,required to meetthe requirements,ofthcse 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 Pav`e'ments ere Assent,please revkw Restoration requirements with the Highway Superintindenl)
a) Complete all back=fill&'soil compaction work its needed,to provide a 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(2.5')inch compacted lift of Asphalt'Base'Course;
c) Install a one and one half(I: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-
I-7. Trcnchin of Pavement »rrttces'Exceedin One hundred 100' Tcct in Len tit: All trenching of
pavbm"t surfaces exceeding 100'in len&h-inuit'first be feednstrpeted to meet the requirements of Item
0 16 as noted above. Once all paventent reconstruction is completed to the sAiisfactiori 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!Iy
Road Opening Permit Request nationalgrid
TMEv WEHOFACTM
Municipality: ?�+k/i1/,.� ,�. to� Work Order: v3
Location: 4.jd CJ Lo &,4, A/ / Grid:
Town: �(/Ek/sstfci,K Requested By:
;j
Reason
cif�rz:
Reason For Excavation:
Description: /_ 4'Y-4 >e V 8G&A& 4116
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* * * RECEIPT * * *
Date: 03/27/17 Receipt#: 217403
Quantity Transactions Reference Subtotal
1 Excavation Permits 1204 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#37674 $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: BONNIED Internal ID: 1204