HomeMy WebLinkAbout535 Sigsbee Rd Permit No. 1
TOWN OF SOUTHOLD 1psulFo�x�,
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958 a
T102027889 (631)765-3140 °1
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 tate job site.
Print orTt,Rc 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.
Nmne of Contractor Phone Number Address of Contractor
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner
4 535 SIGSBEE RD - W/S, 610' S/0 MAIN RD, MATTITUCK
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 o Applicant
Application/Permit form Is
Required for a complete application! 12/05/17
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 ror this project.
(c) Work covered by this application may not commence before issuance of n Highway Excavation Permit by tite Town Clerk.
6. Tax Mnp No.: District 1000 , Section_ —, Block Lot 10
7. Starting Date: 1/2/18 Completion Date: 1/3/18
8. Work Schedule: Phase Completion[late
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,tite Utility being modified.
10. Estimated Cost of Proposed Work: $ ---
11.
—11. Remarks: Open (1)44 MAC bell hole on the W/S SIGSBEE RD, 610'S/O MAIN RD to install gas service
D-39 1 of 3
12. Insurance Coverage:(Attach Copy)
(a) Insurance Company:
(b) Policy P:
(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:
$1,000,000 ,per Occurrence and S 2,000,000 general aggregate.
13. Security:
(a)Surety Band or Certified Check provided In the total Amount of$
(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. IServiee Connections excavations Q 520.00 g 20.00
No.
A2. /Additional Excavations same service Q S 10.00 S
No.
B. Excavations 18"in depth or less
0-100 L.F.=$10.00;Additional L.F.Q 50.10 $
C. Excavations 18"in depth to 5' in depth
0-100 L.F._$30.00;Additional L.F.®$0.30 S
D. Excavations 5'in depth and over
0-100 L.F._$50.00;Additional L.F.Qa $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 ol'permit.
� * + •a a . 4 � ¢ � ar � � v
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway E eavation permit to:
_ in accordance
this application and subject to the"General Conditions"and"Special Conditions"of permit f any)attached re
SUPERINT D OF S
TOWN OF U •W RK
ince r
�n r Date
� (�
Date Received by the Tow Cler� o�-l I l�
Tante Permit Issued d0 1 (I PermitNo. `� 1
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: 'L.' S
- Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
REMARIZS
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
APPLICATIONMERMIT FOR HIGHWAY EXCAVATIONAND REPAIR
1. Permittees Contractors to Cointily with Permit Rem�irerncnts:-The Permittee is responsible for
informing its independent contractors;employees,agents andyassips of their responsibility to comply with
this permit,including all speciil/site specific and general conditions imposed by the Highway
Superintendent while acting as'thc permittee's agent with,respect to the permitted activities,and,such
persons shall be required to comply with all permit requirements.
2. No Riaht'lo Tresnnss or Interfere tivith PrivRte 11ro6-ert0Rights: This-permit does not convey to the
permittee any`right to trespass upon the lands of adjacent property owners in order to perform thepermitted
work nor does it authorize the impairment daisy rights,title,or'interest in real or personal property held or
vested in a per'so'n not a party to the IpeI mit.
3. Protection of the'Ilialrivny and Tuturc IIiahwnv Maintenance: If future operations or highway
rimaintenanoe 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 maybe revoked if the Highway Superintendent finds tbaf the issuance,of the
permit was illegal or unauthoriied bithat 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 Hisbwav Superintendent: If the Highway'Superintendent deems"it
necessary to•revoke this permit and the project hereby authorize '
d has not been c6mpleted,'the applicant
shall,with expe, ise�to the Town and to such extent and in such time and manner as the Superintendent
May,requAire,remove all orany portion of the uncompleted utility,structure or fill and restore the site to its
foiznei condition.
5. Notice of Commencement: At least 24 hours•prior to commencement of the,project,thepermittee 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. Storage of Equipment&Materinls: 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 m`an`ner-that does not interfere with normal highway traffic.
7, Utility Marti-Outs:-The Applicant/Contractor'shall be responsible for verification of all existing utility
mark-outs and shalltake 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 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 PERMYT
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 thddownslope edge of any disturbed area,.This sediment barrier is to be put in place before any •
disiurbattoe of the ground occurs acid is to be maintained in good functional canditiop 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 oi'de'molition debris)..All unsuitable soils"excavated at the site(i.e.Clay,Hog, etc)arc to
be removed from the site and not used to backfill atiy-exeavation within a Town Highway.
.12. _AA Areas bf 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 of planting is 6practical,due_to the season,tlten
the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions favor
germination.
13. Mickfill&Coimnaction of iin Excavations: Back Fill shall consist of clean fill or soils which exhibit a
veli=deftned ritoisture'den"sity`relationship as determined to be in accordance with A§111D 698: Fill shall
be placed in maximum lifts of twelve(12')inches thick and sha1I be ineclianically compacted to a.Ninety-
five(95%)percent maximum dry density. Suitable hydraulic compaction by water jel#ing atthree-foot
intervals will also be permitted subject to'a project specific appioval by the Highway-Superiintendent,
14. Restoration of t6 Road Shoulder Arca: All man-made improvements located within existing road
shoulder areas'must b" rotected to the'greatest extent practical: Items would include.but not be limited to
driveway&privata'road aprons;snail boxes,sprinkler systems;trees and ornamental plantings.
Excavations_"through driveways and private`rodd pavements must be reconstructed to mee'tall requirements
of SoSpecifications, All pre-existing solid shoulder improvements that have been
uthold Town Highway,
disturbed during construction must be replaced or,repaired by the contraefor to the satisfaction of the
Highway 5uperintenden-
15. Schemntic Plaits with A Technical information nail Scone orMorlc: To reasonably and adequately
describe the proposed work,,aaburate'seliematic site pians 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'coecrete pavements. Accurate ske of bell holes o'width
of trenching must be indicated by dimension'or labeling: This sc4iemiitic site plan must piovidc details on
all'restoration required to meet the reiluiretnents 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 regtiltements with the Highway Superintendent)
a) Complete all back-fill&soi!compaction work as needed to provide a suitable sub-base;
b) Over-cut existing asphalt bell,h'ole 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(2.51)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 Surfiices Exceeding One IIundeed(100')Tcet in Length: All trenching of
pavement surfaces exceeding lQ0' 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).
si ly
n tion l ri
F EIM TQC "MI TION SKETCH
Village Of
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DATE. 121412017
LOCATION: 585-SIGSBEE RD GROSS STREET If MAIN RD �
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T OWN- MATTITUCK CROSS STREET Z: PECONIC BAY BLVD
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* * * RECEIPT * * *
Date: 12111/17 Receipt#: 229989
Quantity Transactions Reference Subtotal
1 Excavation Permits 1245 $170.00
Total Paid: $17000
Notes:
Payment Type Amount Paid By
CK#40045 $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. 1245