HomeMy WebLinkAbout150 Budds Pond Rd * * * RECEIPT * * *
Date: 08/11/17 Receipt#: 227340
Quantity Transactions Reference Subtotal
1 Excavation Permits 1224 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#38862 $170.00 National, Grid -Gas Permits
Dept
c
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, 1224
f
Permit No.
TOWN OF SOUTHOLD �gOFFfJI,�c
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958
T101987000 (631)765-3140 'a�
APPLICATION/PERMIT FOR HIGHWAY 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 the job site.
Print or 1,R 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' Picone Number Address of Contractor
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner
4 150 BUDDS POND RD- E/S BUDDS POND RD, 155' N/O BAY HOME RD, SOUTHOLD
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. -
Margaret Paglia
NOTE: All information requested by this Signature of Appii t
Application/Permit Form Is
Required for a complete application! 08/01/17
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 n Highway Excavation Permit by the Town Clerk.
6. Tax Map No.: District 1000 , Section 5( , Block Lot
7. Starting Date: 08/29/17 Completion Date: 08/30/17
8. Work Schedule: Phnse Completion Dale
Excavation Warlc Schedule
Facility Installation Must be provided
Backfill&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.
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 0:
(c)State whether policy of certification on file with the Highway Department:
(d)Coverage required extended to die 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 - $150.0
A Pioject 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 2 0.00
No.
A2, ��/Additional Excavations same service()a $10.00 S
No.
B. Excavations 7 8"in depth or less,
0.100 L.F.-=$10.00;Additional -L.F.Q$0.10 S
C. Excavations 18"in depth to 5'in depth
0-100 L.F.=$30.00;Additional_1.F.®$0.30 S
D. Excavations 5'in depth and over
0-100 L.F.s$50,00;Additional L.F.Q$0.50 $ _
E. Utility Repair Excavations Q$10.00 S
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.
Authorizniion is hereby granted to the Town Clerk of the Town of Southold to issue wHighway Exca adon permit to:
n accordance '
this application and subject to'the"General Conditions"and"Special Conditions"of permit(if y) tached re
SUPERINTE I
TOWN OF S ,N W K
Vince .Or!
Date
Date Received by the To vn lerk
Date Permit Issued Permit No. L of of q _
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
15`
2nd
3rd
4m
(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 OF PERMIT
APPLICATIOMPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
1. Permittee's Conti netnrs to Comnix with Permit Requirements: The Permittee is responsible for',
informing its icidependentcontractors,employees,agents and assigns of their responsibility to;comply with
this'permit,-including all speciallsite.specific and general conditions imposed by the Highway
Superintendent while acting as the Permittee's agentwith respect to the permitted activities,and such
persons shall be required to comply with all permit requirements.
2. No Itiuht io Tresoas's orIntcrferc with Private Property Rights: This permit does not convey to the
permittee any right to trespass upori,the lands of adjacent property'owcters in orde-'r 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;nota party to the permit.
-3. Protection of the Highway and Future Iliahivity Maintenance; 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 pcdorme'd under
this permit shall cause unreasonable obstruction-to required highway maintenance or endanger thehealth,.
safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility,
structure,fill,czcavation,or other modification of the highway hereby authorized shall not be completed.
Additionally,the permit may be revoked if the Highway Superintendent finds that the'issut�itce bf the
perni t_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. Reyoeiition of the Permit by the Iliebway Superintendent: If the Highway Superintendepf deems it `
necessary to revoke this-perniit acid the project hereby authorized has not been completed,the applicant
shi 1.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 f II and restore the site to its
former condition.
5. Notice of Commencciricnt: At least 24 hours prior to commencement of the project,the permittee and/or
shall notify the Town Highway•Departcnent in writing thafthey are fully aware of and
understand all terms and project conditions of this permit. Upon completion of the work,the contractor
shall provide photogrnphs�of the completed work to the Town Highway Department and request a Final
inspection.
6. S(amee of Equipment&Materials: The storage of construction equipment and/or'materials shall be
confined withidthe project work area•andlor'adjaccnt 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 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,. T_erciporary 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
w for single lane traffic, Road Closures due to unforeseen
flag men to stop and start traffic to allo
emergencies require.i''iediate 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
sitc'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
APPLICATIONMERNIIT FOR I-IGHWAY 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 biurier 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. Clenn 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 Disturb'arice: Ali'areas of soil disturbance resulting from the.approved project shall be
stabilized to the satisfaction of the Highway Superintendent immediately following project completion. If
the project site remains inactive for more than 48 hours or planting is impractical due to the season,then
the area shall be stabiiiied with straw,hay mulch and/or jute matting until weather conditions favor
germination.
13, Baclifrll-&Corn :ration of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a
well-defined moisture density relationship as determined to'bc 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-
fve(9_ %V percent maximum dry density. Suitable hydraulic compaction by water jetting attltrce-foot
intervals will also be permit#ed subject a pioiceispecific approval',by the Highway,Superintendent, -
14. Restoration of ilia Road'Shoulder Area: All man-made improvements located within existitig'road
shoulder areas must be protected to the greatest extent practical. Items would include but not be limited to
driveway&private road aprons,mail boxes,sprinkler systems,tree, and ornamental plantings:'
Excavations through driveways and private road pavements must be`reconstructed to trieet all requirements
of Southold Town Highway Sp`ecificatiotis, All pre-existing road shoulder improvements that have been
disturbed during caristruction must be replaced or repaired by the contractor to thesatisfaction-of the
Highway Superintendent.
15. Schen tic Plans with all Tceltnical information and Scene ofVork: To reasonably and adequately
describe the proposed work,aceuiatischematic site pians must be provided to show or indicate ail
proposed construction activity required under this permit: All Pavement surfaces scheduled for excavation, ,
must be'saw cut to the full depth of asphalt ind/6f concrete pavements. Accurate'siie 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 Oeheral 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 aro Present,Please review Restoration requirements with the Highway Superintendent)_
a) Complele 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 Hlend base(RCA Blend must meet 14YS DOT Specification);
d) Install a two and one half(2.5'�inch compacted lift of AsphaltDase Course; _
c), Install a one and one half(1.5")inch of Asphalt(Type ti)\Vearing Course. (Provide AC at all,joints)
All work listed herein must meet the minimum requirements of the Southold Town Highway"
Specifications.
17. TrefichintE of Pavement Syefitces Exceed in One hundred 100' Fcct in Len ilt: All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
# 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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PETI T A MICATI0N SKETCH �
-Village Of
DATE: 713 112017
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LOCATIM 150 BUDDS POND R0tROSS STREET I:, BAY HOME RD
TOWN: SOUTHOLD CROSS STREET-2:
WCIM-ORDER: T101987000
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