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HomeMy WebLinkAbout1815 Peconic Bay Blvd Permit No. TOWN OF SOUTHOLD HIGHWM'DEPARTMENT Peconic Lane Peconic,New York 11958 T101954224 (631)765-3140s�` ,,u�a®�: APPLICATiON/PERMIT FOR-HIGHWAY TXCAVATION AND Ri:PAIR 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 applicable lawa, 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'Te Keyspan Gas East Corp D/B/A National Grid Gas Permits Dept. Bldg: 3 Fl: 1 1 Keshia Black 516-545-4686 175 E. Old,t6untry 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 1815 Peconic Bay Blvd - N/S, 90: E/O N Oakwood D,r Grass Bellhole) 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 may be required. NOTE: All information requested by this Signature of Applicant Application/Permit Form is Required for a complete application! 5/8/17 _ Date 5. (a) Attached plot pian to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the locntion 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 Highway Excavation Permit by the Town Clerk. 6. Tax Map No.: District 1000 , Section , Block , Lot 7. Starting Date: 5/29/17 .. ._ Completion Date: 5/30/17 S. Work Schedule: Plhnse Contniction Dale Excavation Werk Schedule Facility Installation Must be provided Backfill S,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. d 10. Estimated Cost of Proposed Work: S 11. Remarks: demo related gas service installGrE D-39 1 of 3 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: (b) Policy 0: (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: $1,000,000`per Occurrence and S 2,000,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (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$20.00 S No. A2. ___.j Additional Excavations same service Qa S 10.00 S No. B. Excavations 18"in depth or less 0-100 L.F.=$10.00;Additional L.F.Q$0.10 $_ C. Excavations 1S"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.©$0c50 $ E. Utility Repair Excavations Q$10.00 $ No. Repairs same service Q$5.00 $ Additional TOTALS 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 Excava'on permit to: _ in ccordance wi this application and subject to the"General Conditions°'and"Special Conditions"of permit(if any attach SUPERINTENDS Y TOWN OF SOU T O EW 0 Vince ndg—/A Date V � � Date Received by the Toi 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: Permit# 4C k Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RE,CORDS Inspection Date Findings(use code) Applicant Notified 15` 2nd 3rd 4u` (To Permit Clerk) REiViIARIKS CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due to backfilIinz) BUC Building Under Construction WIP Work In Progress DB Improper Backfill(too high,not sufficient) HFS Inspector Holding for Final Settlement of Excavation OR Ready for Repair D-39 3 -of 3 GENERAL CONDITIONS OF=PERl&lI ` ,, APPLICATIOy/P,ERMIT.F,OR„HIGHNVAY=IGXCAVATION-AND;REPAIR J., P&mitleels Cantradlors to Coninly w 11,Terinit'Rcdtlkciii”"eats:"the Permittee is responsible for- ormiiig;its,iadepondenf'coritraetors;,cmployces ugents`ari'dwiissigns of their responsibility io comp1y with this permit','inclutling all'speciaUsite specific and'gencral conditions`imposod by the l Iighway Sapermtendent w'06 acting tis th'c perniittee's,at;ent wtth respect,to the permitted activities;and such persons shall be•required to comply with;all permit requirements. This permit�do 2. No Riaht ta.Tresn:iss or Intcrfci-c•svitlr Priys�ie I'roticrty`Riebts:� cs not convey to the peiinittec any,right to trespass upon the lands'cif adjacent property owners Iii ordor,to perform the permitted work nor does it authorize the impairment"of any'rights,title,,or-interest idreal or personal property held or vested'in a person,not a party to the permit, ' 3, Protectign of the lliehiinj andTuture lilighwU�Malntenance',,If-future operations or highway ; maintenrince pro�ects:by the Town of Southold 'require an alteration tri thc;position af.thc utility,structure or work,hercin authorized,-o if,in the opinion of the Highway Superintendent the work performed under this permit shall cause'uhreasonable;obAruction to required Highway maintenance or endanger the health, safety and/or-welfare of vehicular or'pedestrian'traffic,this permit`sirall be xevotced and,the utility;' structuie,-fill;excavation,or other modificution'of the highway hereby auttiarizec shall not be completed: A1.dditionally,'the permit may be rcVAM if the Highway Superintendent finds that the issuance of the permit was iliegal or;pnautho"r`ized orthat the applicant failed to comply with any of th®terms and condition's of the permit or Chapter 237 of the Town,Code: ; 4, Revocation of the Permit by the IIiehwav Sunerintenderit:-.If the,Highway Superintendent deems it necessary to revoke'this permit and the project hereby-suthorized has riot been completed,the applicant shall,.without expense to the Town and to such extent and;in such time and manner'ns the Superintendent may,require; e,move,all orany,pbiiion of the uncompleted utility,:structure or fill and restore the site to its former condition. S. Notice•of Commcneeinent::At ledsst 24 hours-prior to,commencement of the project,the permittee and/or contractor shall notity'the Town Highway Department tri writing'that they are fully aware of and understand all term's and pioject 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 Final inspection, 6. Storage of Equipment arc-Miitcrinlsi The storage of construction equipment andlor materials shall be confined within the project work area and/or adjacent areds'where permission/legal access has been . obtained iri a manner that does not interfere with normal highway Oafiie. 7, iJtifity Mark-Odes: The Applicant t Contractor shall be.re$ponsible for verification of all existing utility' m-ok=outs and shill take all precautions to protect same,. Damage to existing utilities shall be the resporisibility of the contractor and,shall be repaired at the contractor's expense. S: 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. This item will included but not be.limited to the installation of appropriate signage and Pig men to stop and start triflic to allow for single lane traffic. Road Closures due to unforeseen emergencies require immediate f notiication of the Highway Department and shall be limited to ime mediat and/or expedited restoration.of the Work Zone. 9, No Construction-Debks in Road Shoulder Arca: All Construction Debris shall-be removed from the job site on a daily'bnsis;_All'stockpiledsoil 6 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. -GENERAL CONDITIONS®F PERMIT APDL,ICATIONMERMIT,FOI2,I•iIGHWAY EXCAVATION AND 1ZEPAAIt " (Continued) 10. Install,M( int:iin Rrosion Conirals: Required Erosion Control Measures(i:e,silffencing)is to be placed on the downslope edge of ally disturbed area,•-This sedimeot.barier is tube put-in place,before any ; disturbancc of the ground occurs arid'is to be ritaintained in good functional condition until thickwegetative cover,is,established. i 1.'Clean h'i 1 Only:•Ail project back-fill shall consist of clean sand,gravel orsoil(RIOT asp halt,_slag,,flyash, iirokeri eoncrete`o�'derriolition debris}. Ail unsuitable soils•excavated at the site(Ce..Clay;Bog;etc)are to be removed from the site and not used to backfill any excavation within ti Town High tiy. 12. All Areas of Soil IDiOuOl ance: All areas of soil disturbance resulting'"from the approved project shall be stabilized to the satisfactiod'oftlie Highway Superintindet t immedia%ly following project cotripletion."If the"project site rcmains'inactive for more than;48 hours or,planting is impraotieal due to the season,then the area shall be stabilized,with'stiaw,bay_mulch and/or jute matting until weather eondltiotis favor germination. U."Backfill S:C6Mr-tcti6n of all Eitcavations: Back Fill shall consist of clean fill or snits which exhibit.a well=defined moisture density relationship as deierinined to'be in accordance:with AS'f MD.698. Fill shall be placed in maximum/itis of twelve(l2'�in'ches thick and shall be mechanically Pornpacted'to a N nety- five(95%)percent maximum dry•dersity._ Suitable hydraulic compaction by.water jetting atibree-foot intervals will also be permitted subject to_a project specifeapproval by the Highway„Superintendent, 14,,'RestoFhti6n of the'Road.8lio6Idcr,Area: All man=made improvements located within existing road shoulder areas must be:prote"cied to the greatest extent practical. Items would include but not be limited to driveway.&private roadsapTtins; 4-4 natio'. 'I rod- v 11- 1 .1---n g cc a ai r ICATION S TC- " iliage�Of cd d- =isa : 5181201 . �b LOCATION: 181-5 PECONI -BAY L s-srREET is N OAKWOOD-RD- � W) .,T OYM: LAUREL Citass.srl EET 2:: MCDONALD,RD MK ax6Ep,: T10`1,9 4224: SURFACE:Grass/Dirt � A of, o o <.. p � 77. b 0 90' n� •� 44"Bell Hole, cn 0 PECONIC:BAY BLVD � * * * RECEIPT * * * Date: 05/16/17 Receipt#: 219749 Quantity Transactions Reference Subtotal 1 Excavation Permits 1209 $170.00 Total Paid: $17000 Notes: Payment Type Amount Paid By CK#38137 $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: BONNIED Internal ID 1209