HomeMy WebLinkAbout335 Hill Rd Pe;rmtt No.
TOWN OF SOUTHOLD �o�}Efat&%
HIGHWAY DEPARTMENT
Peconie Lune
Pecortic,•New York 11958
T101947324 (631)765-3140lq;
APPLICATION/PERMIT FOR HICAIWAY VXCAVATION AND nTPA1R ;-
APPLICATION IS HEREBY made to the Supciintendeat of Highways orthe Town or Southold for the Issuance of on Excavatiop Permit
pursuant to Chaplet 237 of the Codd orthe Towa or sduihold,Suffolk County,Naiv York;and other applicable laws;ordiaaiiccs or
raguletions,for each individual contiguous excavation project herein dcson'tied:The applicant agrees to comply with Al oppiicible laws,
ardinanccs,codes acid rbgulations;the attached"Gcnerol Conditions of Permit"and"Special Conditions",If any and to perrnit'authorized
inspectors to make necessary inspections of the job site.
Print or-1 y rl a Keyspan Gas East Corp D/B/A,National Grid
Gas Permits Dept.'Bldg: 3 FI c 1
1• '5165454094 . 275 E.Old,CoukEj Rd Hicksyilie, NY, 11$01
Name of Applicant Phone Number Address of Applicant
2.
Name of Contractor PhonoNumber Address ofControctor
3.
Name of Property Owner Requesting Service(irapplicable) Address of Owner
4 335 HILL RD-N/S, 276' W/O HARPER ST„SOUTHOLD, 275' W/O"HARPER RD
Work Description and location(Street Number,Hamlet,Cross Street)
(a) Is constntctlon located within 75 flet of tidal watlands4 •Yes, No
•If yes,other Town permits may be required.
Margaret Paglia
NOTE: All inforinatlon requested by this Signature of Applicaldt
Application l Perrirl 'r,01- •m is
Required,for a complete applicatlont 4/6/17
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 oreas,-and givc'a detailed description of
all site and pavement restoration work.-
(b) Attach all other necessary permits and licenses ror this project.
(e) Work covered by this application may not commence berom issuance ora Highway Excavation Permit by lite Town Clerk.
6. 'rax Map No: District 1000 : Section 10 . Block, l.ot- I
7. Starting Date: 5/5/17 Completion Dale: 5/6/17
8. Work Schedule: Pbnge Caronletion_t)ntc
EXCaVation Work 5c1cedule
Facility installation Must ba provided
Backfill&Completion for cons tderotloa•as a
Pavement Replacement Complete ikpplicaiinn.
9. Under which authority Is application being made: Keyspan Gas East Corporation d/b/a Natiorial Grid
See Town Code Chapter 237(E).Provide Resolution by,or authority from,the Utility being modified.
ill. Estimated Cost of Proposed Work: S
11. Remarks:.OPEN(2)4'X4'X4'GRASS BELL HOLES ON HILL RD TO INSTALL NEW RESIDENTIAL SERVOCE
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12. Insurance Coverage:(Attach Copy)
(a) Insurance Company:
(b) Policy#• }
(c)State whether policy of certification on rife 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 number of Project Locations shall be subject to the approval of the Highway Superintendent,
A1. /Service Connections excavations Q 520.00 S 20.00
No. ;
A2. /Additional Excavations same service Qn $10.00 S------
No. __No.
B. Excavations 18"in depth or less
0-100 L.F.=$10.00;Additional L.F.Q$0.10 $ _
C. Excavations Ili"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 �70.00
F. Notice to public utilities proof must be provided and
Shall be attached to this application prior to issuance of permit.
s * � � � � � t s r ► r � s
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Exca ation permit to:
accordanc
this application and subject to the"General Conditions"and"Special Conditions"of permit(if y) ache er o.
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SUPERINTEN OF S
TOWN;OF S t ORK
JV I Vincent
�l/l,� I
Date Received by the Town(Clerk a e
l
Date Permit Issued ""l(1 1� 1 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.
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Copy Distributions
Permit#
Highway Department
Engineer(with page 3)
Applicant-
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
1st
2nd
3rd -
nth
(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
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GENERAL'CONDITIONS OF-.-PERNIIT;
APPLICATION!PERMIT;FORHIGHNVAYIEXCAVATION-AND;RFF'AIR '
I. Pai'MItICc'S Cejffiactors.t16 Cbm61y iyii'li'Pcrinit Renitiremetits:` The Perrriitiee is responsible for
iriformiag its itidcpgndeat contractors;employees,ugents'iiitdFas`sipns of thele responsibility to'comply with
>, ; M
this„permit,incl uding a11,speciaUsite specif a and general conditions imposed by;the Highway
Superintendent wl►ile acting as thie permittee'-agent with respect to the permitted activities,'and succi
per shalt be ieyuir`ed to comply;witliall permit requgements.
2. No Richt to Trespass a Jntcr`Pcre,wilh-Priynie 1'r6perfy'Riehls: This permit does not convey to.the
permittec`any°right to trespAs"s upon'the lands of adjacent pcoperty owners in'order_to,perform the Persriitt,ed r
work nor does it nuthorizc the impairment of any'rights,title,°or in in real'or personal property held or
vested iri a person not a,partyto thepermit," _
3. Protection of the Ilisiiwiiv and Future Ili elnvay'Mnifit onanew,If future operations or highway
mainteniince projects,°by'the'Town of Southold requirc;an alteration itm'the position of the utility,structure
or work herein authorized,or if,:in the opinion of the Highway Superintendent the work performcd under
thispermit shall cause unreasonable' struciion"to rcquir'ed highway maintenance or endanger the health;
safety• and/8r44are of vehicular or pedestrian traffic,this permit shall lie"revoked and the utility,` -
structure;fill;eiccavatian,'or other modification of the highway hereby authorized shall not•be completed.
Additionally,the permit'may be`'revoked if the Highway Spperintifdent,ftnds that the issuance of the
permit was illegal or'tinauthorized or that the applicant failed to comply with any of the terms and
condons of&,p
erFn if or Chapter 237 of the Town Code.
4.' Revo6iion ortite Permit,by the Hiehway.Superintendent: If the Highway Superintendent deems it .
necesspry"to revoke,this permit and the project hereby Authorized has not been completed,the applicant
shall,without expense to-the Town And toIsuch extent and in such time and"inanner as the Superintendent
may require,remove all or any portion of the uncompleted utility,structure or fill and cestore the site to its
former condition.
5. Notice bf Commencement: At.leaA 24 hours_prior to commencement of the project,the permittee and/of-
confiktor shall notify the Town Highway Department in writing that they are fully.awarc of and
u-n&rstarid all terms and project conditions of this permit._ Upon completion of the work,-the contractor,
shall provide photographs of the completed work io the Town Highway Department and request a Final
inspection.
6. Storaue ofEguinntent,&Materinis: The storage of construction equipment and/or materials shall be
confined within the project work area and/or adjacent a eas where pecniissiori/legal access has been _
obtained in a matiner that doe's'not interfere with normal highway traffio.
7; .Utiliiy Mark.041s: The Applicant/Contractor shall be responsible"for verification of all existing utility
mark-'gists --ad shrill take all precautions to protect same, DamaSe to existing utilities shall bc',the
responsibility of the contractor and shall be repaired at the cantractor's expense. ,
8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town
B'oaid prior to closing a road. Temporary lane closures may be permitted with the approval of the Highway
Superiiitendeni. This item will included but not be limited to the installation of approprii►te signage and
flag men to stop and start traffic to'allow for single'lanoItraffic, Road Closures due to,unforeseen
emergencies require immediate'notification of the Highway Department andshall be'limited to immediate
and/or=expedited restoration of the Work Zone,' ;
9. 'No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job
site on a`daily basis,'All stockpiled soil a"s"well'ns 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.
' GENERAL CONDITIONS OYPERMI
AMLICATIONME,RMIT FOR RIGHWAY EXCAVATION AND,REPAIR
- : , -. _ -, - (Continued) r, , -•, _ • -
10. Install.Mainti Erosion'Controls:,Required Erosion Control Measures(L-e.silt.fencing)is to be planed
on`the.down`slopegdge of any disfurtied area,;This`sediment ban-ier is to be put in place fiefo�e any
disturlianec of the ground occurs and is to 6e maintained in good functional condition until thick vegetative
cover is established:
11 i Clcan`Fill;Only: All project back-fill shall consist of clean sand,gravel or soil-(NOT asphalt,slag,flyashi,
,. y...r•tx lv ,
broken concrete or'demolition deb'ris).`All unsuitable soils_excavated at'the site(i.e:Clay,F Bog,ete:)are to
be,removed from the site and not used to backfill any excavation within a Town Highway.
12.-'Ail Areas of Soil Disturbance: Ali areas of soil disturbance resulting from the approved project shall be
'stabilized to the stitisfaction'of the-Highway Superintendent immediately following project completion. If
,the_project,site remains inactive for;morc than'48 hours or.plagting is impractical,dae to the season,then
the•area`shall be stabilized"with straw,hay.mulch and(dr jute matting u"
-weather conditions favor
germination.
13. ,lld kfill'6c Camniiction of till Excavations: Back Fill shall consist of clean fill or soils which exhibit a
well=defined moisture"t _"'de ' I'"relationship-6 determined to be in accoidancc with ASTMID 698: Fill shall
be placed in maximum lifts of twelve(IT)inches thick an'4 shall be meclianiciilly'cdmpacted to-p Ninety-
fve(95%°)percent maximum dry ,density. Suitable hydraulic compaction by waterjetting attliree-foot
intervals wilt also be permitted subject to,a project specif c approval by the Highway Superintendent,
14, Restoration of.the Road Sltould&Arew All man-made"improvements located within existing road
shoulder aretis must be'protected to the greatest extent practical. Items would'include but not be limited to
drivewiy`&private road aproits,rmail boxes,sprinkler systems,trees and ornamental pltintings:
Excavatians'through drideways Lind private toad pavements must be'reconstructed to,meet all requirements
of Southold Town Highway Specifications, .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.
I5. Schematic Pians with all Techni6al information and Scone of,Work: To reasonably And adequately
describe the propflsed woik,accurate schematic site plafis must be provided to show or indicate ail
proposed canstructioii activity required underthis permit. All Pavement surfaces scheduled for'excavation •
must be saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of belildles or width `
of trenching must be indicated by dimension or labelidg. This schematic site plan must provide details on
all restoration required to meet the,iequirerncnts of these General Conditions and requirements found in the
Southold Town Highway Specifcatio6s.
16. Pavement Reconstruction: All Pavement sections must be reconstntcted in'the following manner;
(Note:When Concrete Pavements are Present,Please review Restoration,requirements with ttro mghway Superintendent) '
a) Complete till 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) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification);
d) Install,a iwo and one half(2.5")inch compacted lift of Asphalt Base Course;
e) 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. "
I7. Trenching of Pavement Surfaces Exccodint'`Onc Iluntlred(1110'1Tcet in Length: All trenching of
pavement-surfaces exceeding 100',in lefi&h must first be reconstructed to meet the requirements of Item
N 16`as noted above. Once all pavement,recenstruetion 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
repavid with a two(2") inch'lift of Asphalt(Type 6)Wearing Course(Typical;shoulder to shoulder).
• Road Opening Permit Request nationalgrid
THE POWER OF ACTON
Municipality:Town of Southold Work Order:T101947324
Location:335 Hill Rd Grid'108180430
Town:Southold Requested By:Brian Romano
Reason For Excavatiori:Install one new residential gas service {
Description:Two 4'x 4'x 4'grass bell holes on Hill Rd,approximately 275'West of Harper Rd
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Curb Line
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2751 ••--a
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Hill Rd i
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335
Permit sketch may not include excavations required under 16 NYCRR Part 7'53 Revision:0
Typical trench width is 12"wide,Typical bell hole excavation is 4'x 4'x 4' Date Submitted:4/6/17
Not To Scale Number Of Permits Requested:1
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* * * RECEIPT
Date: 04/07/17 Receipt#: 217788
Quantity Transactions Reference Subtotal
1 Excavation Permits 1205 $170.00
Total Paid: $17000
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Notes:
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Payment Type Amount Paid By
CK#37794 $170.00 National, Grid - Gas Permits.
Dept
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
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Name: National, Grid -Gas Permits. Dept
175 E Old Country Rd
Bid 3 FI 1
Hicksville, NY 11801
Clerk ID: BONNIED Internal ID. 1205