HomeMy WebLinkAbout300 Harper Rd y
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* * * RECEIPT * * *
Date: 11/06/17 Receipt#: 229498 '
Quantity Transactions Reference Subtotal
1 Excavation Permits 1235 $17000
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#39671 $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
Bld 3 FI 1
Hicksville, NY 11801
Clerk ID: LYNDAR Internal ID. 1235
RECEIVED
Permit No. ��� NOV - 6 2017
TOWN OF SOUTHOLD �gUfFO,t,��
HIGHWAY DEPARTMENT
Peconie Lane Southold Town Clerl
Peconic,New York 11958
T102016945 (631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION 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 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 Type Keyspan Gas East Corp D/B/A National Grid ,
Gas Permits Dept. Bldg: 3 FI: 1
I 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. 300 HARPER RD W- S/S, 285' W/O WELLS AVE, 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.
Alyssa Davan
NOTE: All information requested by this Signature f Applicant
Application/Permit form is
Required for a complete application! 10/31/17
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 a Highway Excavation Permit by the Town Clerk.
6. Tax Map No: District 1000 , Section (Os-, Block 2L- , Lot 1
7. Starting Date: 11/28/17 Completion Date: 11/29/17
S. Work Schedule: Pltnse Completion Dale
Work Schedule
Excavation
Facility installation 11]ust 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.
10. Estimated Cost of Proposed Work: S ---
11. Remarks: Open (1)4x4 MAC bell hole on the S/S HARPER RD, 285'W/0 WELLS AVE to install gas service
D-39 l 1 of 3
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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 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 - $150.00
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. /Service Connections excavations Q$20.00 S 20.00
No.
A2, /Additional Excavations same service Q 510.00 S
No.
B. Excavations 18"in depth or less
i 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.®S0.30
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 Excava n permit to:
in ccordance '
this application and subject to the"General Conditions"and"Special Conditions"of permit(if an at7--ehedh et .
SUPERINTEND T
TOWN OF SOF V Y
/ L4-//
incept M. rl pn�d�/��iY�
Date
Date Received by the Town Clerk Idul
Date Permit Issued Permit No. 1 et 3�5_
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
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Copy Distribution:
Permit
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
e
1 sl
2nd
3rd
4th
(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 PERMff -
APPLICATIONMERMIT FOR HIGHWAY EXCAVATION AND REPAIR
I. Permittee's Contractors to Comply with Permit Requirements: The Permittee is responsible for
informing its independent contractors,employees,agents and assigns of their responsibility to comply with
this,permit,including aII special/site specific and general conditions imposed by the Highway
Superintendent while acting ns the perinitice's agent with respect to the permitted activities,and such
persons shall be required to comply with all'permit requirements.
2. No Right to Trespass ar Inierrere wiIli Private Property Rights: 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 oupersonal property held or
vested in a person not a party to the permit,
3. Protection of the Ilighway and future Ilielnsay 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 performed under
this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health,
safety and/or welfare'of vehicular or pedestrian traffic,,this permit shall be revoked and the utility,
structure,fill,excavation,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 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 I.3iehwav Superintendent: If the Highway Superintendent deems it
necessary to revoke this permit and the project hereby authorized has hot 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
former 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 tlfey 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. Storage of Equipment&Materials: The storage of construction equipment and/or materials shall be
confined within theproject work area and/or adjacent areas where permission/legal access has beeti
obtained in a manner that doe's not interfere with normal highway traffic.
7, Utility Mark-Outs: The Applicant/Contractor shall'be responsible for verification of ail 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 toad. 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 Area: All Construction Debris shall be removed from the job
sitc'on a daily basis. All stockpiled soil as well as all other project niaierials 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.
i
GENERAL CONDITIONS OF PERMIT,
APPLICATION/PERhGT FOR I-IGHWAY EXCAVATION AND REPAIR
(Continued)
10. Install,knininin Erosion Controls: Required Erosion Control Measures(i.e.silt fencing)is to be placed
an 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. 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 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 '
the project site�remains inactive for more than 48 hours or planting is,impractical'due to the season,tlien
the area shall be stabilized with straw,hay mulch and_/or jute,matting until weather conditions favor
germination.
13. Backrill&Compaction of n11 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
5 be placed in maximum lifts of twelve(IT--1 inches thick and shall be mechanically compacted to a Ninety-
flve(95%)percent maximum dry' density. -Suitable hydraulic compaction by water jetting at three-foot,
intervals will also be permitted subject to a project specific approve!by the Highway Superintendent,
14. Restoration of the'Rond Shoulder Area: All man-made intprovcments located within existing 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,trees and ornamental plantings.,
Excavations through driveways and-private road 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. Schematic Plans with all Technical information and Scone of Worl{: to reasonably and adequately
describe the propesed 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 pavements. Accurate size 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 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 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;
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. Trenching of Pavement Surfaces Exceeding One Hundred(100')Tcet in Lent*tlt 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)1Wearing Course(Typical,shoulder to shoulder).
- slly
national grid
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a MRUM "M KATION SEITCH o
Village Of
u
DATE: 10/3012017 �
88
LOCATION: 300 HARPER RD W CROSS STREET 1: WELLS AVE N
TO%VN: SOUTHOLD CROSS STREET 2: GRIGONIS PATH
woRx ORDER: 7102010945
SURFACE: -'
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