HomeMy WebLinkAbout1055 Skunk Ln Town of Southold
P.0 Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/11/18 Receipt#: 250128
Quantity Transactions Reference Subtotal
1 Excavation Permits 1308 $550.00
Total Paid: $550.00
Notes:
Payment Type Amount Paid By
CK#43316 $550.00 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: LYNDAR Internal ID 1308
Permit No.
TOWN OF SOUTHOLD �l
HIGHWAY DEPARTMENT
Peconic Lane
W.O. T102150507 Peconic,New York 11958
(631)765-3140 lop,
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.
Priv e Keyspan Gas East Corp D/B/A National Gl1d
Keshia Black 516 545-4686 Gas Permits Dept. Bldg:3 ll: f
1. ( ) 175E 01 Coun � 111% KHOO
Name of Applicant Phone Number Address of Applicant
2. _
Name of Contractor Phone Number Address of Contractor
2. __
Name of Properly Owner Requesting Service(if applicable) Address of Owner
a 1055 Skunk Ln -- E/S, approx 1065' S/0 Main Rd-- (1) 4' x 4' bellhole
Work Description and Location,(Street Number,Hamlet,Cross Street)
(a) is construction located within 75 feet of tidal wetlands? °Yes No X
*If yes,other Town permits may be required.
NOTE: All Information requested by this Signature of Applicant
Application/Permit Form is
Required for a complete application! 12/3/18
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 of a Highway Excavation Permit by the Town Clerk.
6. Tax Map No.: District 1000 , Section A�, Block , Lot-
A ---
7. Starting Date: 12/31/18 Completion Date: 1/1/19
8. Work Schedule: Phase Completion Date
Excavation Work Schedule
Facility Installation Must be provided
Backfill 8c 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. Remarks; Install gas service
D-39 1 of 3
12. lnsurance 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$2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided: 2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee for Each Project Location - $500.00
A Project Location would include each Bell Hole andfor every roa 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. t /Service Connections excavations @$50.00 $ 50.00
No.
A2. /Additional Excavations same service @$20.00 $
No.
B. Trench Excavations 18"in depth or less
Total Lineal Footage of Excavation; d. _L.F.@$10.00 $
C. Trench Excavations 18"in depth to 5' in depth
Total Lineal Footage of Excavation; L.F.@$30.00 $
D. Trench Excavations 5' in depth and over
Total Lineal Footage of Excavation; L.F.@$50.00 $
E. r Utility Repair Excavations @$1,000.001 Each $
No.
y Additional Repairs of Same Service @$500.00!Each $
TOTALS 550.00
F. Official 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:
iWordance 'ththis application And subject to the"General Conditions"and"Special Conditions"of permit(if nyo.
SUPERINTE TTOWN OF S TH
'Vincent M.'Orla o
I — 1' d
Date Received by the Town Clerk Date
Date Permit Issued t a ,
— l I"I �/ Permit No. :'�)f 6
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:
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECT'OR'S RECORDS
Inspection Date Findings(use code) Applicant Notified
1st
2nd
3rd ,
41h
(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
I:. Permilice's Contractors to Coin&with Permit Reel eirenrenis: The Permittee is responsible for
informing its'mdependent contractors,employees,agents and assigns of their responsibility to comply with
this permit, including all speeial/site specific and,general conditions imposed by the Highway
Superintendent while acting as the permittee's agent with respect to the,perm itted activities,and such`
persons'shall be required to comply with all permit requirements.'
2., Nu Ri ht to Tres ass'nr Interfere with Private Progoty 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 Ifttthwav and Future Hiobwair 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 steall cause unreasonable obstruction to required highway maintenance or endanger,the health,-
mit
ealth, -
safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the uti!ity;
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. Rcyocation of the Permit bv'the Highway Superintendent: If the Highway Superintendent deems it
necessary to revoke°this permit and the project hereby autharized has not been completed,the�applicant
shall_,without expense to the Town and to such'extent and in such time and manner its the Superintendent
may require,remove all or any portion of the uncompleted utility,structure or fill and restore the site"to its
former condition.
S. 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 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.
ti. Storage of Eauinment&'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. Wilily Mark-Outs- The Applicant/Contractor shall be responsible for veritication 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 thecontractor's expense.
S. Road Closures: All scheduled road closures must first receive written permission from the Southold Town
Board prior to closing a road, Temporary lone 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 CONDI'T'IONS 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(he downslope edge.of any disturbed area., This'sediment barrier 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
egetativecover is established.
11. Clean hill Only: 'All project back-fill shall consist of clean sand,gravel or soil(NOT asphalt,stag,flyash,
broken concrete or demolition debris). All unsuitable soils excavated at the site(i.c.Clay,'Bog,ate.)are to
be removed from the site and not used to baokftil•any excavation within aTovrn Highway..'
12., All Areas of Soil Disturbance: All areas of soil disturbance resulting from•the approved project shall be
stabilized,to the satisfactton of the Highway Superintendent immediately following project completion. If
the project site remains inactive for more than 48 hours or planting is impractical dud to the season,then
the area shall be stabilized'with straw,hay mulch and/or jute matting until weather conditions favor
germination.
13. Backiitl 8t Coinpaction of ail Excavations: 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
be placed in maximum lifts of twelve(12')inches thick and shall be mechanically compacted to a Ninety-
five(95%)percent maximum dry density. Suitable hydrauliccompaction by water jetting at three-foot
intervals will also:be permitted subject to a project specific approval by the.Highway Superintendent.
14. Restolaiion of the Road Shoulder Area: All man-made iinprovements located within existing road '
shoulder areas must be protected to the greatest extent practical. Items would includebut 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 requirertient'a
of Southold Town Highway Specifications. All pre-existing-road shoulder improvements that have been'
disturbed during constructiommust be replaced or repaired'by the contractor to the satisfaction of the
Highway Superintendent.
15. Schematic flans with all Technical'information and Scoge of Work: To reasonably and adequately
describe the proposed work,accurate schematic site plans 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 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 Reconstruction: All Pavement sections,must be reconstructed in the following inanner;
(Note;^When Concrete Pavements arc Present,Please review Restoration requirements 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 trench by twelve(1211)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. Trenchinti of Pavement Surfaces Exceediei ,One Hundred lowFeet in•Len lk: All ttenching`of
pavement surfaces exceeding 100'in length utast 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 andler 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).
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