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Home My WebLink About2675 Hobart Rd Permit No.T FF TOWN OF SOUTHOLD %u 91,f, HIGHWAY DEPARTMENT Peconic Lane T102102664 Peconic,New York 11958 (631)765-3140 , . t,Z 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 the job'site. Print or Tyne Keyspan Gas East Corp D/B/A National Grid Gas Permits Dept. Bldg: 3 FI: It Melissa Trotman 516-545-5046 1. 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 2675 Hobart Rd - N/S,100' E/O Old Shipyard Ln--Bellhole 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 r quired. NOTE: All information requested by this Signature of Applicant Application I Permit Form is 7/23/18 Required for a complete application? 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 o hwaa Excavation ermit by;Cule lerk. 6. Tax Map No.: District 1000 Section� ock 5 Lot7. Starting Date: /� Completion Date:8. Work Schedule: Phase Com ionExcavation Facility Installation Must be provided Backfill&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. Re rks: Gas Service Install _ ._Gti R= nu. D-39 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 Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed: $1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: (a)SuretyBond _ or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Applications and permits: Basic Application Fee for Each Project Location - $500.00 A Project Location would include each Bell Hole ands{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. A1. Service Connections excavations @$50.00 $ 50'0 No, A2. 1 Additional Excavations same service @$20.00 $ No. B. Excavations 18"in depth or less 0-100 L.F.r$1,000.00;Additional _ ^__L.F.@$10.00 $ C. Excavations 18"in depth to 5' in depth 0-100 L.F.=$3,000.00;Additional L.F. @$30.00 $ D. Excavations 5' in depth and over 0-100 L.F.-$5,000.00;Additional L.F.@$50.00 $ E. Utility Repair Excavations @$1,000.00 $� No. _- _ . - Repairs same service @$500.00 $ Additional TOTAL$ 550.00 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 Excavation permit to: _in accordance th this application and subject to the"General Conditions"and"Special Conditions"of permit f any)attached he to. SUPERINTE SDE F AY TOWN OF O YO X r 61/1._ Q� Date Date Received by the Town Clerk + l� Date Permit Issued--� I S Permit No. 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.. 2 of 3 D-39 Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 15' 2nd e 3 rd 4th (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 !. Permittee's Contractors to comply iti:Permit Reauirecnents: The Permittee is responsible for informing its independent contractors,employees,agents and assigns of their responsibility to comply with this permit, including all special/site 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 Tresnass or Interfere with 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 or personal property held or vested in a person not a party to the permit. 3. Protection of the Highway and Future Highway 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 Highway Superintendent- 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 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 they are fi:11y 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 Enuinment& 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 has been obtained in a manner that does not interfere with normal highway traffic. 7. Utility Mark-Outs: The Applicant/Contractor 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 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. 00 o i � o a TE1tMU AMICICATIONSKETCH Village Of -iiATE,. 7/2-1/2018 LO QkTICK: 26775'-HOBART RD crosssrrEET-.I:- 'OLDSHIPYARDIN 'T,OVM: SOUTHOLD QRO$S,STMET 2: TERRY LN WORK oRuEiR: Tt02l-O'2'6-64- on SURFACE: Macadam Rcl dam, floum Na r. ❑ 2675 C-- P. CL PO cn n Cd CL, b Cd 1,OQ 4" 4' Bell-Hole 0 -HOBART AVE ' 4 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 08/01/18 Receipt#: 246658 Quantity Transactions Reference Subtotal 1 Excavation Permits 1276 $550.00 Total Paid: $550.00 Notes: Payment Type Amount Paid By CK#42174 $55000 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: JENNIFER Internal ID. 1276