HomeMy WebLinkAbout400 King St Pennit No.
TOWN OF.SOUTHOLD suFFOtq-�,
HIGHNVAY DEPARTMENT
Peconic Lane "4;
Peconic,New York 11958e
T101963210 (631)765-31401;:.
APPLICATION/PERMIT FORHIG11WAY EXCAVATION AND 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 lades,ordinances or
regulations for each individual contiguous excavation project herein described. The applicant agrees to comply with 411 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.
Printor'I'vnc Keyspan Gas East Corp D/B/A National Grid
Gas Permits Ddpt.-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.
Mame of Property Owner Requesting Service(if applicable) Address of Owner
4 400 KING ST -S/S, 115' E/O WILLOW TERRACE LN, ORIENT
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. -T
Margaret Pa Iia G
9 9
NOTE: All information requested by this Signature ofAp cant
Application/Permit 1,orm Is
Required for a complete applieatlonl 05/19/17 _
Date
S. (a) Attached plot plan 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 a Highway Excavation Permit by the Town Clerk.
6. Tax Map No: District 1000 , Section Chock , Lot
7. Starting Date: 06/15/17 Completion Date: 06/16/17
S. Work Schedule: Phase Completion(Date
Excavation Work Schedule
Facility Installation Must be provided
Backfill S Completion for consideration as it
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.
10. Estimated Cost of Proposed Work: S
11. Remarks: OPEN (1) 4'X4' MAC BELL HOLE TO INSTALL GAS SERVICE
D-39 I of 3
12. Insurance Coverage:(Attach Copy)
(a) insurance Company:
(b) Policy#:
(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 number'of Project Locations shall be subject to the approval of the Highway Superintendent.
Al. 1 /Service Connections excavations Q$20.00 S 20.00
No.
A2. /Additional Excavations same service Q$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 18"in depth to 5' in depth
0-100 L.F.=$30,00;Additional L.F.Q$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 Exc tion permit to:
in accordance%v'th
this application and subject to the"General Conditions"and"Special Conditions"of permit(i any) the e
SUPERINT D F AY
TOWN Or O L ,N O
Vinc o
SIS f� Date -_-
Date Received by the Town ClerkQ3� f
Date Permit Issued ��PcrmitN�ol
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
nth
(To Permit Clerk)
REMARR5
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•PEE MIT '
APPLICATIONMERMIT FOR HIGHWAY.EXCAVATION ANI}REPAIR
1. Permittae'c Catitractnrs_to'Coritrilyivith Permit Rcrtiiirements: The Permittee is'reusponsible'for
,.,
informing its ihdepcndent contra"c"tors;employees,agents an'd assigns of their"respons1ib!ty to'cotriply with
this peiinit,'including all speckYsite specific hrid general conditions imposed by the Highway,
Superintendent while acting as the permittce's agent with respect to the permitted activities;and such
persons,shall be reyuired'to comply with"all permit requirements.
2. This permit does not convey to the
peii.nitt'c'e any right.to trespass upon the lands of adjacent property owners in order to perform�thc permitted
work nor does it authorize the impairment 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 0ighway and Future Iiiglliwnv'Mnintcnance: If future operations or highway
maintenance projects'by the Town of Southold require an alteration in the position of the utility,structure
or work herein authorized,or if,in the opinion of the Highway Superintendent the work performed under
this,-pennit shall cause unreasonable obstruction to required highway maintenance or,endangerthe health,
safety and/or welfare of vehicular or pedestrian traffic,this permit shall lie revoked and the utility,
structure,fill,excavation,or other modification of thAighway hereby authorized shall not be completed.
Additionally,the permit may be rcyoked 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 Chapter 237 of the Town Code.
4, Revocation of the Permit by the Iliehwav Sunerinte4dent: 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
may,require,remove all or any portion of the uncompleted utility,structure or fill and restore,the site to its
for her condition.
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 Final
inspection.
6. Stoiran of I:nuinment&Materinls: The storage ofconstruction 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 Mnrlc 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.
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
flag men to stop and start 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 restoration of the Work Zone.
9. No Construction Debris in Road Shoulder Arca: 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.
-GENERAL CONDITIOhiS OF PERIVII<T. -
APPLICATION/PERi4 IT.FOR,'IIIGHWAY,gXCAVATION AND fi*PAIR
(Cont hued) ;
10. Install.Mu ia`tain,I±,r'asiou Controls: 'Required Erosion Control Measures(i.e;silt fencing)is to be placed,
on`the downslope edge of any disturbed area.-This sedimen_t barrieris to be`put in place„Gefore any
disturbance of the ground occurs,and is to be rhaintained'in goad functional caridition until-thick vegetative
cover is established.
11. Clenn till Oniy: All projectback-fill sha11 consist of'clean sand,gravel or soiI(NOT aspha%_slag,flyash,
Broken con`cr`ete or demolition debris).'All unsuitable sails excavated'at the site(he.Clay,-Bog;etc.)are to
be'rdmoved from the site`and not used to backfill any excavation within-a.Town Highway.-
, - - . ,-
12.- All Areas of Soil Disturbances All areas of soil disturbance resulting from the,approved project shall be
stabilized to the satisfaction of the Highway Superintendenfinimediately,following project completion. If
the"projecf site remains inactive for more than 48 hour&or planting,is impractical due to-the season,then
the area shall be stabilized with straw,haymuich and/or jute matting until weather conditions:favor
germination.
13. ]3acicriIL&Cotnnsiction of iilI'Eacnvations: -Back Fill shall consist,of clean fill or sails which exhibit a
veli-defined;moisture density reliitionship as-determined to be in accordance with ASTMD 698.,Fill shall
be placed in maximum lifts of twelve(IZ')inches ihick�und'shall be meclianically cainpacted to a PJinety-
five(95%°)percenfmaximum dry density: ,Suitable hydinulic compactiori.by wgter jetting atthree-foot
intervals will also be-pertnitted subject to a project-specific approval by the Highway Superintendent.
14. Restoration of tlic Road Shoulder Arai:.All frail-made improvements located within existing road
shoulder areas must be protected�io the-greatest extent practical. Items would'idciude'but not be limited to
driveway&private road aprons,ima I boxes,sprinkler systems,trees and oinamental,plantings. -
Excavations through driveways and privi te'road pavements musi be reconstructed to meet all'requirements
of Southold Town Highway Specifications, All pre-existing roadshoulder'improvenients'that have been
disturbed-during`construction must be replaced pr repaired by the contractor to`the satisfaction of the
Highway Superintendent:
15. Selienintic Plnns Edith all Technical information and Scone of Werk: ,To reasonably and adequately
describe the proposed work,a6e'urate-kh6matic site'plans'rntisi be'prdvided to show or indicate all
proposed construction activity required under this permit. All Pavement surfaces scheduled'far excavation
roust be saw cut to the full depth of asphalt and/or concrete pavements, Accurate size of bell holes or width
of trenching must be indicted by dimcnstan or labeling. This schematic site'plan trust provide details on
all restoration required'to meet the reilidiements of these General Conditions and requirements found in the
Southold Town Highway.Specifications.
16. PaveMeet Reconstruction: All Pavement sections must,be reconstructed in the,following manner;
(Note:When Concrete Pavements are Present,Please review Restoration requirements with the Highway Superintendent)
a} Complete-all back-fill&sdii'compaction work as needed to provide a suitable sub-base;•
b) Over-cut existing asphalt bell hole or trench by twelve(1'2")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 compacied'lift of Asphalt Base Course;
C) Install a one and one half(1.51-)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. Trenchingof Pavement Surraces I;xceedin' One Hundred 100' Teet in Length' All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to mee(the requirerrients of3tem
# 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).
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* * * RECEIPT * * *
Date: 05/30/17 Receipt#: 220952
Quantity Transactions Reference Subtotal
1 Excavation Permits 1212 $170..00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#38242 $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. 1212