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Home My WebLink About1235 Oaklawn Ave 4 * * * RECEIPT * * * Date: 04/20/17 Receipt#: 218403 Quantity Transactions Reference Subtotal 1 Excavation Permits 1207 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#37901 $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: LYNDAR Internal ID, 1207 Permit No. TOWN OF SOUTHOLD �gUFFt7,t�%� HIGH`'VAY DEPARTMENT Peeonie Lane I! Peconic,New York 11958 T101951905 (631)765-3140ad;; �°� APPLICATION]PERMIT FORNIGIIWAY EXCAVATION AMID REPAIR 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;and other applicable laws,ordinances 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 inspections of the job site. Print orTyll Keyspan Gas East Corp D/B/A National Grid Gas Permits 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 Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(inapplicable) Address of Owner 4 1235 OAKLAWN AVE-E/S, 550' N/0 JERNICK LN, SOUTHOLD Work Descriptlon 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. fJ Margaret Paglia NOTE: All information requested by this Signature of Appiic t Application/Permit Form is Required for a complete application! 4/13/17 _ 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. (e) Work covered by this application may not commence before issuance of a Highway Excavation Permit by the Town Clerk. 6. Tax Map No.: District 1000 . Section , Block '5 , Lot 7. Starting Date: 5/11/17 Completion Date: 05/12/17 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfitl&Completion for consideration as it Pavement Replacement Complete Application. 9. Under which authortty 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 M (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$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 numbernf Project Locations shall be subject to the approval of the Highway Superintendent, Al. /Service Connections excavations Q$20.00 S 20.00 No. A2, /Additional Excavations same service an $10.00 S _ No. B. Excavations 18"in depth or less 0-100 L.F.=$10.00;Additional L.F.@S0.10 S 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 of permit. Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: in actor n this application and subject to the"General Conditions"and"Special Conditions"of permit ' any tta ed e e . SUPERINTE TG YS TOWN OF S D NES , ORI ince Oda 11 rt Date Date Received by the Town Clerk ��6� t Date Permit Issued L�" 1)0 0 �_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) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 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 D-39 3 of 3 GENERAL CONDITIONS 0YPERIVHT APPLICATIONMERMIT FOR HIGHWAY,EXCAVATION-ANDMEPAIR 1. -Peemitlee's Cnntractors to Coninlv'ivith`Pcrmit Renuirements:,.The Penitittee is responsible for informing its independent contractors;employee's;agents and assigns of their responsibility to comply with this.pertnit,'Ic ing all special/site specific and'gencral conditions imposed by the Highway, " Superintendent while acting as ttie perinittee's agent with respect to the permitted activities',and such persons shall be required to comply with all permit requirements. 2. No Rieht to Tresn:iss ar Intcrfc're<svilfi Privaic I'ronerty Riuhls: This permit does not convey to the permitter any rightto trespass upon the lands of adjacent property owners in order to,perfortn the permitted worknor does it authorize the impairment of any rights,title,or interest in real or personal property held or vested ins person not a party to the permit. 3. Protection of the Ilighwav and Future IIi hwnv)Mnintennnees If future operations or highway maintenance projects'by the Town of Southold requir`c an alteration in the position of the utility,structure or work herein a_uiliorized,'or if,in the,opinion of the Highway Superintendent the work performed under this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health, safety and/or we of vehicular or pedestrian traffic,this permit shall be revoked and the utility, structure,fill,excavation;or other modif cation of,thc highway hereby authorized shall not be completed. Additionally,the permit may be rcvokrd 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 terms and conditions of the permit or Chapter237 of the Town Code. A. Revocation orthe Permit by the Mobwav Superintendent: If the Highway Superintendent deems it necessary to revoke this permit and the project hereby authorized has not been completed,the applicant shall,without expense to the Town and to such extent and in such time and manner as the Superintendent. Tay require,remove all orany portion of the uncompleted utility,structure-or fill and restore the site to its former condition.- 5. ondition.-5. 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 Finn] inspection. 6. Storage of Equipment&Mterinls: 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 a manner that does not interfere with normal highway traffic. 7, Utility Mnrlt-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility mark-outs and shall take all Orccautions 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 may be permitted with the approval of the Highway Superintendent. Ibis item will included but not be limited to the installation of appropriate signage and flag men to stop and start'traffic to allow for single lane traffic, Road Closures due to unforeseen emergencies require immediatenotification of the Highway Department and shall 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 sas oil well as all other project materials that will be staged within the 'w Right-of Way must be delineatedith reflective signage or other means to meet the minimum requirements of the NYS DOT Construction Standards. GENERAL CONDITIONS OF PERIYIIT APPLICATIONMERMIT FOR'HIGHWAY EXCAVATION AND REPAIR (Continued) 10. Install,Maintain Erosion Controls: Required Erosion Control Measures(i.e:silt fencing)is to be placed ori th'e downslope edge of dry disturbed area. This sediment barrier is to be put in place,befoig any disturbance of the ground occurs and is to,be.mainidined in good functional condition until thick vegetative cover is•established.' i 1. Clenn Fill Only: All project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash, &liken concrete oi'demolition debris). All unsuitable soils excavated at the site(i.e.Clay,Bog,etc)are to be removed from the site and not used to backfill any excavation within a Town Highway. 12. All Areas of Soil Disturbance- All areas of soil disturbance resulting from the-approved project shall be stabilized to the satisfaction'of the Highway Sup'eriniendent immediately following project completion. If the-project site remains inactive'for;more than 4-hours or planting is impractical due to the season,then the area shall be stabilized'with straw;hay.niulch and/or jute matting until weather conditions favor germination. 13. lld&rirll&Com' Paction of all Excavations;_ Back Fill sliall consist of clean fill or sails which exhibit a well-defined moisture density relationship as determined to be in accordance with ASTMD 698. Fill shall be placed in maximum lifts of twelve(12')inches thick and shall be mechanictilly compacted to aNinety- five(95%)percent maximum dry;density. Suitable hydraulic compaction by water jetting atthree-foot intervals will also be permitted subject to a project specific approval by the Highway Superintendent. 14. Restoration of the Road Sliouldcr Area: All man=made improvements located within existing road shoulder areas must be protected to,the greatest extent practical. Item's would include but not be limited to driveway' private road aprons,mail boxes,sprinkler systems,trees and ornamental plantings. Excavations through driveways grid private road pavements must be reconstructed to meet all requirements of Southold Town Highway Specifications. All pre-existing road shoulder,improvements'th'at have been disturbed during construction must be replaced or repaired by the contractor to the satisfaddi l ofthe Highway Superintendent. 15. Schematic Plans with nll-Technical information and Scope of Work: To reasonably and adequately describe the proposed work;adci:i6fe sohJe atic site plans must be provided to show or indicate all proposed construction activity required under this permit.'All Pavement surfaces scheduled for=excavation must be saw cut to the full depth of asphalt and/or concrete pavements. Accurate sixe of bell holes or width of trenching must be indicated,by dimension or labeling. 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 Pavements arc Present,Please review Restoration requirements with the Highway Superintendent) a) Complete all 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 two 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 mus_t meet the minimum requirements of the Southold Town Highway' Specifications. 17. Trenching_ of Pavement Surraces Exceeding One Hundred(100')Tect in Length All trenching of pavement surfaces exceeding 100' in,length must first be reconstructed to meet the-requirements of Item #1 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(Type 6)Wearing Course(Typical,shoulder to shoulder). s)ty W (D naion, MIUM�"M,ICAT-ION SXETCH- 4 Village Of- d8 DATE'.- 411212017 ,LOCATICN- 1235 OAKLAWN AV CROSS STIZEET-1: JERNICK LN C> 'sbUTHbLID CRPSS$7 REE T 2:;' ROUTE-2 5' wcr..K-,or,D,,-Ep,: T 1 b--1,9 5 0 5-, 03 m tn to bj) an HoiumNa-- ,-Macadam RQ8 d o�'- kn 1,2- 5 u :D, ra 0, fy� af LU C-. x P4 CE cc c� bA 650 cd 4 eBelrHoIe0 �4 OAKLAN'AV W