HomeMy WebLinkAbout445 Pike St Permit No.
H G WAY DE ART'M N'T
PeconicL'ane,
Peconic,New,Yor1c 119584 s '^
T102014450 (G31)765-3140
APPLICATION/PERMIT FOri NIGIIWAY"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 or Southold;Suffolk County,New York,-and other applicable laws,ordinances or
regulations for each individual contiguous excnvaiion project liereindescribed. The applicant agrees to comply with all applicable laws,
ordinances,c,'odes and regblations,'the Attached"General Conditions of Permit"and"Special Conditions';if any And to permit authorized
inspectors to make necessary inspections of the jbli site.
Print or'fvnc _ Keyspan Gas East Corp b/B/A National Grid
Gas Permits Dept."Bldg: 3`1=1; 1
L 515 545 4094E, 175 E. Old'Country Rd-Hicksville, NY ,11801
Name of Applicant''', Phone Number Address of Applicant
Nnmc of Contractor Phone Number Address of Contractor
Name of Property Owner Requesting Service(if applicable) ;Address,of Owner _
445 PIKE ST-E%S, 98' E/O LOVE LN-MATTITU' K.
Work Description'and Location(Street Number,Hamlet,Cross Street) "
(a) ls,construction located within-75 feet of tidal wetlarids? Yes No ,
*if yes,other Town permits may be required.
Marg6ret Paglia
NOTE: "All information requested by this, Signature of Appiicari
Applientiu'n/Permit Form Is
Requlred fora coinplete applientlonf, 11/6/17
-Date
S. (a) Attached plot plan to reasonably and adequately describeAl a proposed work. Provide accurate scherhatic 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,ull othernece`ssary permits and licenses for this project.
(c) %York covered by this application may not commence before issuance of Highway Cxcavation Permit by the Town Clerk.
J96.- Tax Map No.: District 1000 , Section o" , Block- , Lot
12/5/17 - 12/6/17 .
7. Starting Date: ; Completion Date:
8. Work Schedule: Plinio Completion Darr"
-Excavation Work'Selredule
Facility Installation Must be provided
Backfill S Completion for eonsideration ns a
Pavement Replacement Complete Application.'
9. Under whicfi authority is application being made: Keyspan ecus EastCoippratiOtl d�/IJ/a National Grid,
Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified.
10. Estimated Cost of Proposed Work: S
11. Remnrks::Open & restore Q1)4'x4' rwao bee holle in the S/E/S of Pike St,`aperox 98' E/® Love Orn
t® iflstaH Gas Service t® above address ,
, _
D-39 �L, 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 number of Project Locations shall be subject to the approval of the Highway Superintendent.
Al. /Service Connections excavations Q 520,00 g 20.00
No.
A2. /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 50.10 S
C. Excavations 18"in depth to 5' in depth
0-100 L.F.=$30.00;Additional t L.F.Q 50.30 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 xcavation permit to:
in aVdh
this application and subject to the"General Conditions"and"Special Conditions"of perm! if a )a
SUPEEtINT TOWN OF 0l D
Vincent M.Ori d
Date
Date Received by the Town Clerk C1r
Date Permit Issued--'=` � �� � Permit No. I
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: y
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
15t
2"d -
3rd
nth
(To Permit Clerk)
REMARKS
CODE
IB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure(due to backfilling)
BUG 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 .
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR ,
1. Permittce'c Contractors'to Comnlvwitli Permit ReiruirentenIis: The Permittee is responsible for
informing its independent contractors,employees,ugents'and,assigns of their responsibility to comply with
this permit, including all speciai/site specific and general conditions imposed by the Highway
Superintendent while acting as the permiriee's agent with respect to the permitted activities,and such
persons shall be required to comply with'all permit requirements.
2. No Richt to Trespass o�Interfere with Private Property'RMkhts: 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 tiny rights,titie,or interest in real or personal property held or
vested in a person not a party to the permit,
3. Protection of the Iligh*nv and Future Highway Maintenance: If future'operations or highway
maintenance projects'by the Town of Southold require an alteration in thcfposition 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,'cxcavation;or other modification of the highway hereby authorized shall not be completed.
Additionally,the permit may be revoked if the Higbway'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 Cbgpter 237 of the Town Code.
4. Revocation of tlmc Permit by the Higbway-Sunerintettdent: If the Highway Superintendent deems it
necessary to revoke this permit and the project hereby authorized ha's 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 eny portion of the uncompleted utility,structure or fill and restore the site to its
former condition.
5. Notke'of Commencetdent:-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-tire'fully aware of and
understand all ternts'and project conditions of flus 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. .Stortme of nipinnment&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 hris been
obtained in a manner that docs not interfere with'normal highway traffic:.'
7, Utiiity Mark-Outs: The Applicant%Contractor shall be responsible for verification of all existing utility
mirk-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. 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
siteon 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 MGHWAY 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 arca; This sedirrient bonier 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 isestablished.
11.-Clean All Only: All project back-fill shall consist of clean sand,gravel of soil(NOT asphalt,slag,flyash,'
broken conciete 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 bistu'rbance:_-All areas of soil disturbance resulting from the,approved project shall be
stabilized,to the satisfaction of the Highway Superintendent immediately followingproject completion. 'If
the project site remains inactive for more than 48 hours or planting is impractical due tothe season,then
the area shall be stabilized with-straw,hay mulch and/or jute matting'until weather conditions favor
germination.
13. IlackGll&Coninnction of n111;zenvations: 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
bc'placdd in maximum lifts of twelve(12')inches thick sand shall be Mechanically compacted to a Ninety-
f ve"(95%)percent maximum dry density. Suitable hydrnuI'. compaction by water,jetting at three-foot
intervals will also be permitted subject to a project`specific approval by the Highway Superintendent,
14.-Restoration or,thc Road Shoulder Arca:All man-made improvcments,locatid within existing road
shoulder areas must be protected to the greatestIextent 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 Toad shoulder improvements that have been
disturbed during construction most be' replaced_or repaired by the contractor to the satisfaction of the
Highway Superintendent.
,15. Schematic Plans ivitlt nil Technical information and Scope of Work:-To reasonably and adequately
describe the proposed work,.aocurate schematic site,plans must be provided to show or,indicate all
proposed,,,construction activity'required under this permit. All Faventeni surfaces`scheduled for excavation
must be saw cut to the Poll depth of asphalt and/or concrete pavements. Accurate siae'of bell holes or width
of trenching must-be indicated by dimension or labeling. This schematic site plan must provide details on
all rest(ration,required to meetthe requirements ofthese Genera 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 Pav"e"ments are Present.Please review Restoration regit"srcments 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 tiench'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;
e) 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(1001)Tcei in Length: All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
9 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
repayed with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder).
sJ ty
Road Opening Permit Request nationalgrid
, ) THE POWER OFACnOH
Municipalrty- �G( b SO LG Work Order Q 4,450
Location 445 Pla SI— Grid- ���-�(�-7"3
Town MAfr-,:Qk1 Requested By: ��f J�hk-& I 141aof 7
Reason For Excavation: .TAIJ 7 efi'LL A 44S-!�5fV/GY,
Description. ��� 7 X 7 X ,��G�- OL� jv Ot -r�z sialA W t4L/WAG f4/&X qV-116
Lo a LAji
AREA
1 ,
SEA uTj.Slllad
"445 4. z
1
r
i
i
i
P�A
.0t LL W'7
AI;4KAAtA Avg
Permit sketch may not include excavations required under 16 NYCRR Part 753 Revision
Typical trench width is 12"wide,Typical bell hole excavation is 4'x 4'x 4' Date Submitted: �!
Not To Scale Number Of Permits Requested �__
* * * RECEIPT * * *
Date: 12/07/17 Receipt#: 229923
Quantity Transactions Reference Subtotal
1 Excavation Permits 1244 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#39741 $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: 1244