HomeMy WebLinkAbout2975 Pequash Ave t _
* * * RECEIPT * * *
Date: 06/20/17 Receipt#: 222792
Quantity Transactions Reference Subtotal
1 Excavation Permits 1217 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#38427 $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: LYNDAR Internal ID. 1217
ITC
Permit No. _
TOWN OF SOUTHOLD \psuFFot�.�
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958
T101967974 (631)765-3140x1 ,
PPLI TION/PERMIT FOR HIGIIWAY 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 laws,ordinances or
regulations for each individual contiguous excavation project herein described. The applicant agrees to comply with all 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 tate job site.
Print or'I)T Keyspan Gas East Corp D/B/A National Grid
Gas Permits Dept. Bldg: 3 Fl: 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(if applicable) Address of Owner
4 2975 PEQUASH AVE-E/S, 429' N/O NORTHERN CROSS RD, CUTCHOGUE
Work Description and Location(Street Number,Hamlet,Cross Street)
(a) is construction located within 73 feet of tidal wetlands? *Yes No
*If yes,other Town permits may be required.
Margaret Paglia [P1kh4ZV,-t
NOTE: All information requested by this Signature of Appl ant
Application/Permit Form Is
Required for a complete application! 6/13/17
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.
(c) Work covered by this application may not commence before issuance of n Highway Cxcavation Permit by the Town Clerk.
6. Tax Map No.: District 1000 , Section ` ®2 Block , Lot A
7. Starting Date: 7/12/17 Completion Date: 7/13/17
8. Work Schedule: Pliace Completion hale
Excavation Work 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,tate Utility being modified.
10. Estimated Cost of Proposed Work: $
1 t. Remarks: OPEN (1)4'X4'X2' GRASS BELL HOLE E/S PEQUASH AVE,TO INSTALL LARGER GAS SERVICE
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
5W 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 520.00 S 2000
No.
A2. /Additional Excavations same service{Qa S10.00 S
No.
B. Excavations IS"in depth or less
0-100 L.F.=$10.00;Additional L.F.Q$0.10 S _
C. Excavations IS"in depth to 5' in depth
0-100 L.F.=$30.00;Additional L.F.®S0.30 S
D. Excavations 5'in depth and over
0-100 L.F.=$50,00;Additional L.F.Q$0.50 $
E, Utility Repair Excavations cQr $10.00 S
No,
Repairs same service Q S5.00 $
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 Excavat n permit to:
i c�rdancc with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if an attached hereto
SUPERINTEND T S
TOWN
OF
SO R
intent Ms0
n � Dnte T
Date Received by time To n Cler �1
Date Permit issued b 11 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# 1 ,^
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RE,CORIDS
Inspection Date Findings(use code) Applicant Notified
151
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
IB Improper Barricades
1L 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 orExcavation
RFR Ready for Repair
D-39 3 of 3
. p
GENERAL CONDITIONS OF PEAYU
APPLICATIONMERMIT FOR HIGHWAY-EXCAVATION AND REPAIR
1, Pcrmitice,s Contractors to CdnlniV with Perinit'Rcatiircuients: The Permittee is responsible for
informing its independent contractors,employees,agents and assigns of their responsibility to comply with
this permit, including all special/ske specific and general conditions imposed bathe Highway
Superintendent while acting as the perinittee's agent with respect to the permitted activities,and such
persons shall be required to comply-with ail perhiit requirements.,,
2. No Right to Trespass or Interfere Willi Privnte Property Blains: This permit does not convey to the
permittee any right to trespass upon the lands of adjacent property owners in order to perform the 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 ilic Higitivay and Future liiglnvny,Mnintenince.,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,theopinion 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 welfare',of vehicular or pedestrian 6iffic,this permit shall be revoked and the utility,
structure,fill,�cxcavation,or other modification of the highway 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 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 erti:e Permit by Lite i-lighwU'Superintendent: If the Highway Superintendent deems it
necessarto 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
foiiner 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
shalt provide photogrnphs of the completedwork to the Town Highway Department and request a Final
inspection.
6. Storage of Equipment&Materials: 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 Mark 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 shalt 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. This item will included but riot be limited to ttic 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 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.
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
`(Continued)
10. Install,Maintain Erosion Controls: Required Erosion Control Measures(i.e.silt fencing)is to be 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 functional condition'until thick vegetative
cover is established.
11. Clean Fill Only': All project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash,
broken concrete or 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 Superintendent immediately,following project completion. If
theproject site remains inactive for more than 48 hours or planting is impractical due to the season,then
the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions favor
germination.
.13. Backfill&Co'awnction of rill Excavations: Back Fill shall consist of clean fill or soils 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 mechanically compacted to a Ninety-
five(95%)percent maximum dry density. Suitable hydraulic compaction by water jetting itt three-foot
intervals will also be,permitted subject to a project specific approval by the Highway'Superintendent.
14. Restorittidn of the Road Shoulder Arca: All man-made improvements located within existing road
shoulder areas must be protected to the greatest extent practical. Items would include but not be limited to
driveway&oflv:ite road aprons,mail boxes,sprinkler,systems,trees and ornamental plantings:
Excavations through driveways and private mad 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.
15. Schemntic Plans with nil Technical informntion and Scope or Work: To reasonably and adequately
describe"thb proposed work,accurate schematic 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 pavetnedts. Accurate size of bell holes or width
of trenching must be indicated by dimension or labeling. This schematic site plan'iiiust 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 Reconstr"uetion: All Pavement sections must be reconstructed in the following manner,
(Mote:When Concrete Pavements are 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 bellhole 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(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.
17, Trenchine of Pavement Surraces Exceedine One hundred(1001Tect in Legglin All trenching of
pavement surfaces exceeding 100' in terigth must first be,reconstructed to meet the requirements of Item
0 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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Road Opening Permit Request nationalgrid
THE my,"cwAcnQN
Municipality: 10,1w of.S."ti .-Ld Work Order: Tp/9679744
Location: .2975 Grid: y/-Q- 8738
Town: CuilA,*4uf. Requested By: AV;w Arz
Reason For Excavation: - L4ST[L A [A,p-,Q 4AS 54RVJGt.
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