HomeMy WebLinkAboutCottage Place Permit No. TPWN
H GHWADYDE ARTMENT
Peconic Lane
Peconic,New Yprk,l 1958', ® ^'
T102019255 (G3lj7ti5-3140
ARLICA`I'ION/PSAMIT FOR,HIGIIWAY EXCAVATION ANI]RTPA]R
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold fo'r the issuance orae Excavation Permit
'pursuant to Chapter 237'oethc'Code'of the Town or Southold,`Suff'olk County,New York,i+nd other appficable laws,°ordinances or'
regulations for each individual contiguous excavation project herein descdbed.,The applicant'agrees,to comply with ail ai0cable laws,
ordinances,codes'and regulatiohs,the attached"General Conditions,of Permlt"and."Special Conditions";if any and to pertri,it authorized
inspectors to make necessary insp_ections of the job site. `
printorTync Keyspan Gas East-Cgij3 D/B/A National Grid
Gas Permits Dept.:Bidg: 3 FI: 1
I. Margaret Paglia 516 545 4094 175 E.,O{ Country Rd Hicksville, NY 118Q1
Name'df Applicant' Phone Number Address of Applicant
Name of Contractor Phone Number`-, Address of Contractor
Name'of Property OwnerRequesting Service"(If applicable) " Address of Owner
4 E/S.COTTAGE PLA N/S KORN,:RD I/O w%COTTAGE PL SOUTHOLD
Work Description and Location(Street Number,'Hamlet,Cross'Street) '
(a),ls con'striiction located within 75 feet of tidal wetlands? *Ye_s No
*Ifycs,other Town pe'rmitsmay be required;
Margaret Paglia
NOTE: All inrormation"requested by this., 'Signature of Applicant
App[i"tion/Permit Form is
Regitlred for a complete application! 12/2/17
i. (a) Attached'plot plan to reasonably and adequately describe the proposed%vok Provide accurate schematic site plan showing the
location of all proposed excavations and relationship-to,adjotnfng premises,public strccts or areas,and give u detailed description or
all site and pavement restoration work.
(b)'Attach,all odier,necessary permits and licenses.for this project.
(c) Work'covered by'this application may not eommence`before,issuance ora Highway Cxcavation Permit by the Town Clerk.
` 6, Tax Map,No. District 1000 Section Block . Lot
12/30/17 TBD'
-7. Starting Date: Completion Date:
8. Work Schedule: Plin.a Completion Date
ExcavationWork Schedule
Facility tnstaltation Must be provided
Backfill S.Completion for consid=eration as a
Pavement Replacement Complete Application.,
9. Under which authority.is application being made: KeyBpaG'Gas East Corporation d/b/a National Grid
See Town Code Chapter 237(E)-Provide Resolution by,br authority from,the Utility being modified.-
10. Estimated,Cost of Proposed Work: g
11. Remarks: Various ®periings- please att6ched SkEitch -dilrec Eonal drill Gae Main %placcerlrlerlt
D-39 1 Of 3 ' -
12. Insurance Coverage:(Anach'Copy)"
(a) Insurance Company:
(b) Policy{1c
(c)State whether policy of certification on file with the highway Department:
(d)Coverage required extended to the Town:
Any Loss incluiiing Bodily injury,property or commercial injury caused by oe aftributableto the work performed:
51,000,000 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 Applicationsand'permits: Q��aO
-Basic Application Fee for Each Project�Location �02 -$150.00 �� `!
A`Project L`acation would include,eacli Bell Hole and/or every road opening or excavation within any
50'Radius.whethec or not they maybe inter=connected by open trench or directionatboring.
The'toial numbertif Project Locations shall be subject to the approval of the Highway Sup"erintendent:
Al. 1'2 /S.crvice Connections excavations Q 520.00 g 240.00
A2, /Additional Excavations same service Q 510.00 S'
No. ,
B. Excavations 18"in depth or less
0400 L.F.=$10.00 ;Additional L.F.Q x0.10
C. Excavations 18"in depth to 5'-in depth, 141.00
0-100 L.F.-$30.00;Additional '°- -LF.,®50.30 , _ S
D. Excavations 5'in depth and over
0-100 L.F._$50.00;Additional LF.'Q$0;50
E. Utility Repair Excavations Q$10.60 S
No.'
.Repairs same service Q$5.00 $
Additional
TOTALS__
F: Notice to public utilities proof must bc,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 it HighwayExc` ation,permit to:
in accordance
this application rind subject to the"General Conditions"and"Spt clal Conditions" _f permit{' any ttacbed r
SUPERINTE O S
TOWN
OF' 1 RK
Vincent M/S
M107
Date
Date Received by the Town Clerk•-
Date Permit issued Permit No:
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 24 bout notice'to Supetinte'ndent of Highways.
Permit must be available of all times,for inspection,on site,during construe inn,
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
15t
2"d -
3rd
(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 of Excavation
RFR Ready for Repair
D-39 3 of 3
GENERAL'CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
1. Perinittee's Contractors to Comnlywith Permit Requirements: The Permittee is responsible for
informing its independent contractors,employees,agents and assigns of their responsibility to comply with
this permit, including all spec'saUsite specific and general conditions imposed by the Highway
Superintendent while acting as the permittee'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 or Interfere with Private I'roncrty 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
tivo"rk no`r does it authorize the' airment•of arty tights,title;or interest in real or personal property held or
vested in a person not a party to ihe4permit:
3. Protection of the Uigtiwnv and Future IIiehival�Maintenance: If future operations or highway
maintenance projects',by the Town of Southold rcquirc 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 icquired highway maintenance or eridangerAhe health,
safety andlor welfare of'vehicdlar'or pcdesirian traffic,this permit shall be revoked and the utility,
structure,fill,excavation,or other modificadon'of the highway hereby authorized shall not tic 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 Hi ghway Su &inteiident: If the Highway Superintendent deems it
necessary to revoke this permit and the project hereby authorized has not been completed,the applicant
shall,-without expense to the Town and to suchextentand in such time and mariner as the Superintendent
may`require,remove all or any portion of the'uncompieted 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 they are fully aware of and
understand all iernts'and project conditions of this it. Uponcompletion of the work,the contractor
shalt provide photographs of the completed work to the Town Highway Department and request a Final
inspection.
6. Storage or Equipment&Materinls: The storage of construction equipment and/or materials shall be
confined within the project work-area andl6rMjAcent areas where permission/legal access has been
obtained in a manner that does not interfere with normal highway traff e.
7, Utility Marlt Outs: The Applicant/Cantractor,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. Temporary lane closures may be permitted with the approval of-the Highway
Superintendent. This item will included but hoi be'limited to the installation ofappropriate signage and
flag men to stop and start traffic to allow for-single lane traffic. Road Closures due to unforeseen
emergencies require imtriediate notification of the Highwiry'Departtrient and shall be limited to immediate
and/or expedited restoration of the Work Zone.
'g. No Construction Debris in Road Shoulder Area: All Construction Debrii 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/PRMIT FOR IUGHWAY EXCAVATION N AND REPAIR
(Continued) -
10. Install,,Wa taiit Erosion Controls: Required Erosion Control Measures(i.e.siltfencing)is to be placed
on the downslope edge of any disturbed area. This sediment ban-ie'r 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: ,Ali project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,slag,flyash,
b'roken''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 Dis'turb'ance: All,areas of soil disturbance resulting from the,approved project shall be
stabilized to the satisfaction of the Highway Superintendent`immedlately following project completion. If
the project,she remains inactive for,more than 48 hour's or planting is impractical;due to the season,then
sh
the area alt be stabilized with straw,Ihay mulch and/or'jute matting until weather conditions favor
germination.
13. Baelctill&Compaction of all Excavations: Back Fill shall consist of clean fill or soils which-exhibit a
well-defined moisture'dens!ty relationship as determined to be in accordance with ASTMD 698. Fill shall
,be placed in mail"mum lifts_of twelve(1'2"}laches thick laid sha11 be mechanically compacted to a Ninety-
five(95%)per'cent maximum dry density:- Suitable hydraulic compaction by water jetting at three-foot
intervals will also be permitted subject to a project specific approval by the Highway Superintendent,'
14. Restoration 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&'private road aprons,mail boxes,sprinkler systems,trees and ornanier"I 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 nil Technical inforrrtntion and Scone of Worin To reasonably and adequately
deseribe't_h6-oropdsed work,accurate schematic site plans must be provided to show or itidicate,all'
proposed construction activity'required under this persalt. 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 tregching 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 Recoastit,etion: All Pavement sections must be reconstructed in the following manner,
(uote:When Concrete Pavemants arc Present.Please review Restoration requirements with the Highway Superintendent)
a) Complete all back-fill&soil compaction work as needed to providea 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 Speelfieatlon);
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)Nearing 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 SurGtces Eicieding One Hundred(1001'r, in'Len tlt: All trenching of
pavement s'u'rfaces-exceeding 100' in length must fust 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)Wcaring Course(Typical ,shoulder to shoulder).
• Sty
ROAD OPENING SKETCH N -
SUEEDIK COUNTY I TOWNUF SD'e HOLD HAMLET WJE
SDUTI OLD
COTTAGE PL
GRID-I'D8171283 —_--�
�k)RIK DRDER:T102019255 lain'R 3
ENGINEER:CLINT ROGER
CONTACT.((631)487-6437
Kr!LINT.R GER@NAT9ONAL`GIR,I,D.COM
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R.,GAD,WA.'OPENINGS e TOTAL PROiE��
Key QT UESC SCZE =SUBTOTAL �
(Alli f21 UVE GAS PST 8`65` 80 SQ.F['.
Typical,Hotta Scale)
Soil Excavation (11 D.RIM P GVEMMG VXY 15 SQ..FC.
(91 TEST, ROLE 3`xY 91 SQ.FT.
=
RaadwsVAsphaEt Excavation TOTAL 1,76 SCg-FT-
DRUILLSUMMARY 9 AL PR A1C
-----•Huebriantaf aeKectiQna4 Dril4 COTTAGE PC = 46D`
Test Rafe I ORN MY. _ 11Y1. n caI I g r-1 d
®
TOTAL — 47G
i
* * * RECEIPT` * *
Date: 12/20/17 Receipt#: 230210
Quantity Transactions Reference Subtotal
1 Excavation Permits 1247 $2,181.00
Total Paid: $2,181.00
Notes:
Payment Type Amount Paid By
CK#40155.40007 $2,181 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
Bid 3 FI 1
.Hicksville, NY 11801
Clerk ID: BONNIED Internal ID* 1247