HomeMy WebLinkAbout1050 Gillette Dr Permit No.
-TOWN OF SOUTHOLD FFolq-�,
HIGHWAY DEPARTMENT
Peconic Lane
,Peconic,New York 11958 4 ,
T102028673 (631)765-3140olt,
APPLICATION/PERMIT f+OR HIGIiWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold for the issuance of an Excavation Permit
pursuant to Chaptgr 237 of the Code of the Town of Southold,Suffolk County,New York,and other Applicable iaws;'ordinances-or
regulations for each individual contiguous excavation project herein described. The applicant agrees to'comply with all applicable lawn,
ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized
inspectorn to make necessary inspections of the job site.
Printa 'f e° Keyspan-Gas East C&P D/B/A National Grid
Gas Permits Dept. Bldg: 3 1=1: 1 "
I 516 545 4004 .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 n' licable) Address of Owner
4 1050 GILLETTE DR- S/S OF MIDLAND PL, 20' E/O GILLETTE DR, EAST MARION
Work Description and Location(Strict Number,Hamlet,Cross Street)
(a) is construction located within 75 feet of tidal wetlands? *Yes No
*If yes,other Town permits maybe required.
Alyssa Davan
NOTE: All information requested by this Signature of Npplicant
Application/Permit Form is
Required for a complete application! : 1/11/18
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 ora Highway Cxcavation Permit by the Town Clerk.
6. Tax Mnp No.: District 1000 , Section , Block . Lot
2/8/18 2/9/18,
7. Starling Date: Completion DateQ
8. Work Schedule: Phnse Completion Date
Excavation __ __ Work Schedule
Facility Installation b9usf be provided
Backfill S Completion for eonsidei-ation as a
Pavement Replacement _ Camplete Application.
0. 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: $ -
11. Remarks: Open (1) 4x4 GRASS bell hole, (1) 6x6 GRASS bell hole,and (1) 100 x 1' x 3' GRASS trench
on-the S/S OF MIDLAND PL, 20' E/O GILLETTE DR to install gas main and service
D-39 1 of 3
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 the Town:
Any Los's 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. 2 /Service Connections excavations Q x20.00 $ 40.00
No.
A2, /Additional Excavations same service Q$10.00 S
No.
B. Excavations 18"in depth or less
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.®$0,30 S 30.00
D. Excavations 5'in depth and over
0-100 L.F.=$50,00;Additional L.F.Q$0.50 $
E. Utility Repair Excavations $10.00 $
No.
Repairs same service Q$5.00 $
Additional
TOTALS 370.00
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 CIerk of the Town of Southold to issue a Highway Ex/ vation permit to:
in accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(i ny)a ched e t .
SUPERINT_E E S
TOWN OF U E1 ORI,'.
Vincent r1 do
Date Received by the Town Clerk to11
Date Permit Issued Permit No. q02
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 ail times for inspection,on site,during construction,
D-39 2 of 3
rt
Copy Distribution: �a L/
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
1st
2nd
Std
nth
(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
GENFRAL'CONDITIONS"OF-PTi✓RMIT
APPLICATION/PERMIT F01MIGHWAY E,XCAVATION A1O REPAIR
A.,
1. Pcrmiitcc's'Centractarsdo'Comm-Ivwith'Permlt'Reaukeiitenisi The Perinitiee is responsible for '
informing its mdepondent,'contract6fi,cniployces;agents and assigns oftheir responsibility to coitiply with
this peiinit,includingtall spec'sai1site specific and'gencral;coriditions imposed by the Highway
Superintendent while acting as the-permittee's agent with;raspect to tlie''permitted activities,and such
-persons shill bc'required to comply with all permit requirements.
2. No Ri ht to Tres ass or Interfere tvim Privnte Oira er ° ][U hts: This permit does not convey to the
perniittec any,right to trespi§s upon the lands,bra
pr`ope'rty owners in order to'perforris the permitted
work noi:does�t autliorize,the impainneni of any righi's title,�oc interest in'real or personal property'held or
v'iiediin a person not a party.to the,perniit,
3, 'PtMec"tkn of the and Future IIielnvay Mainteiiancei'.If.future operations or`highway
maintenance projects by the,Town,of Southold r'equirc up,alteration in thc'position of the utility;structure
or)wo`rk herein authorized,orifin the opinign'of the Highway Superintendent the work performed under
this permit shall'cause unreasonable obstruction to required highway muintenance,or endanger tha.henith,
safety and/or welfare of vehicular or�pedestriar traffic,this permit shall be revokedwand iter utility, ;
structure;fill;cxcavetion,`oi other modification'of the highway.hereby authorized shall not be.coriipleted.
Additionally;-tlie permit may be revoked if the Highway,Superintendent finds that the issuanoe'of the
permit was illegal or`unauthorized or that the applicanE failed to comply with any of the terms and
conditions of the permit or Chapter 237 of the Town'Code.
4. Revocation of 6,Permit b the Iii hwa' Su -erintcrulenf: If the Highway Superintendent deeins it .
necessary to revoke this permit and the project heidliy authorized has nbt been c6moleted,•tlie,app16c t
shall;without expense,to the Town and to such extent and iii such'time and manner as;the Superintendent
may require,remove all"' portion of -un- 'id structure or fill and reslo're the site to its
former condition. -
5. Notice'of Cosiiiricnccment: At least 24 hours prior to commencenzerit of the project,the permittee and/or .
contractor shall notify the Town Highway Department in wfiting that they arc fuily aware of and
uiiders#and all terms and`project,conditions df diis_perinit. Upon completion of the work,,thc contractor
shall'pmv'jde'photographs of the ooinvieted work1to'"the Town Highway'Department and request a Final
inspection.
6. Storaue of-E-ruinment&'Materials: The storage of constructiomequipmentand/or materials Ault be ,
,. i ,,, t - r�_r._
confined within the project`work area andlor'ndjacent'aceas tiJhere permission/legal access has been
obtained in a manner that does riot,interfere with normal highway traffic. ;
7, Uti{ity Marlin-061s:-The Applicant Contractor shall be responsible for verification of all existing utility
mark-outs and'sholl take'all precautions.to prote, same. Damage to existing utilities-steal{ be the
respar sibihty4thecon66tor 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 mad,"Temporary lane closures may be permitted with the approval of the Highway
Superintendent. This item will included but no#be limited to the installation of appropriate signage and
flag men to stop and start traffic to allow for single lane traff c. Road Closures due to unfarescen
emergencies require immediate notification of the Highway D"ep"artment and shall be limited to,immediate
and%or expedited restoration of the Work Zone.
9. No Construction'Debris WRend ShouIdcr Arca: All Construction Debris shall be removed from the job
siteon a daily basis: All stockpiled soil as'well as,all other projectniaterials 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 D6T Construction Standards.
GENERAL CONDITIONS OF PERMYT
APPLICATION/PE_RMIT.FOR I-IGIIWAY EXCAVATION AND 1Zt4 PAIR
(Clo ii i[Cd)
10. Install.Maintatin I;rosio`n Controls: Required Erosion Control Measures(i.e:silt,fencing)is to be placed
an the downslope edge of any disturbed arca,,This'sediment bamer;is`to be'put in place before any
disturbance of the ground occurs and is;to be maiiiia'red_in good futictlonal condition until thick vegetative
cover is established.
11. Clean Tillbity: All project back=fill shall consist of clean,sand,'gravel orsoil(NOT iisp(alt;sing,`flyash, -
broken concrete o�deinoIiti61i debris}: All unsuittible soils excavated at'the site(i.e.Cl -Boa,etc.)are to
be removed-from the site and-not used to backfill any excavation.within'a Town Highway,.
12. ,'Ali Areas of Soil Digturliance:.Ali are"as,of soil distur6rice'resulting froth the approved project shall be ' -
stabilized to the satisfaction°of the Highway Supenittendent ii tinedintely following project completion. If'the project site remains inactive for more than 48 hours or'planting is impractical due to the season;titer,
the area shall be stabilized'with straw,hay mulch and/or jute matting until weather.conditions favor
,
13. B:tckfill&Compaction of hil E csivatioti's ,;Back Fill shall consist of clean fill or soils which exhibit a
.well!defined moisture density''relationship as,deteimined 6o 6 inaccordancewlSTM
th-AD 698.,Fill shall
be placed in mnitimum lifts'of twelve(12'1 inclies'thick,and-shall be tneclianically cottipacted to a,Ninety- ,
li
fvc(9 %)percent`triaximnm dry density. Sultable,hydroulic compaction by water jetting.itfthree-foot
intervals will Also,be permitted subject,to a poject specifc approve)by the,Highway Supetintendent, -
14:Resforsttioit of the Road Shoulder Area: All Titan-made improv-cments located within existing road
shoulder areas must be"protected to the greatest extent practical`Items would incl'tide but ntitbe limited to
driveway.&'private road aprons,mail boxes,'sprinkler system$,trees and ornamental pluntiiigs.
Excovations through drNdways'and ptivsite road.pavements must be reconstructed,to meet all requirements .
of 8authold Town Highway Sp'ecif cations._All pre-existing road shoulder improvements that have been
Aisturbea duffing construction'niust be replaced or repaired by the contractor to the satisfaction of the
Highway Superintendent. ;
15.,Schematic Plans`with all Teeltnical inform'iatioa and Sco a ofWork: To reasonably and adequately
describe the proposed work,accurate scheiitatic_site plats 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 trust be indicated by dimension'or lribeling. This schematic site plan must provide details ori
all restomtiontrequired�ta meet the requirements of these General Condltlons and rcquirertients"found in the
Southold Town'Highway Specifications.'
i 6. Puvcriierit Reconst'r'uction: All Pavement sections must be reconsttuctcd-in the following manner,
(Note:When Concrete pav'e`ments aro Pres,n%,plcase review Restoration requirements with the Highway Superintendent}
a} Complete all back=fill,-8i soil compaction work as needed to provide a suitable sub-base;
b) bver4ui existing asphaltbell hole or trench'by twelve(12")inches on a1l'sides;
c) Install a compacted lift of 4"thick Stone Blend base,(RCA Blend must meet NYS DOT Specification); _
d) Install a two'and bite half(ZNj inch compacted lift of Asphalt Base Course;
e) Install a one sand one half-(l.5")inch of Asphalt(Type 6)Nearing Course: (Provide AC at all joints)
All work listed herein must meet the minimum reyu!rements of the Southold Town Highway
Specifications.
17. Trenchina of Pa`vemetit Surfaces E-secedinj One Iluntlred(100'1Tcet in Length: All trenching of
pavement surfaces exceeding-100' in length must first tie 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 len 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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Road Opening Permit Request natianalgrid
nit MSER OF ACnON
Municipality: Oaiv Work Order-
Grid:
rderGrid: 11.4-,0 7-566a
Town:BAST AA664 Requested By-, �-
Reason For Excavation. � UAAGAS NAld Odd JesEc�y�- p
11,Dz J'G ,4j&fj3
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Description: (1) G XL X� L�LLl�c�L£,��J'�J(�7C3'8!',l1Ki�£ .4wd A 1 X'16,,o')(3?&A(4w
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* * * RECEIPT * * *
Date: 01/18/18 Receipt#: 232855
Quantity Transactions Reference Subtotal
1 Excavation Permits 1248 $37000
Total Paid: $370.00
Notes:
Payment Type Amount Paid By
CK#40397 $37000 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: 1248