Documents

resolution 7 pages

Also attached to this agenda item: AAH Form CLEAN CROTON 0324 April 10th Resolution 71-2024 Adopt a Highway

INSTRUCTIONS FOR COMPLETING THE APPLICATION FRONT OF APPLICATION Three (3) copies of the entire application, work plans and all other supporting documents must be submitted. At the time of application, certain information relative to fees and deposits may be contingent upon determinations to be made by the Department. In such cases, the information may be left blank and remittance withheld until a determination is made. Please complete the following: • Permittee name, address, phone and email address. Provide joint applicant contact information, if appropriate. If there are additional applicants, attach contact information on a separate sheet. • Name and phone number(s) of emergency contact person. • If permit is to be returned to someone other than the applicant, complete this section. • If the guarantee deposit or bond is to be returned to someone other than applicant, complete this section. • Estimate the cost of work being performed in the state highway right-of-way and provide this figure. • Indicate anticipated duration of work to be performed with starting date and ending date. • Indicate the form of insurance coverage to be provided. • Give a brief description of the work that is proposed to be done under this permit. • Indicate whether any overhead and/or underground work (5 foot or greater depth) is included in the proposed work. • Plans and specifications should accompany this application for any work that involves construction within the state highway right-of-way. Place a check mark on the lines for plans and specifications if they are attached to this application. • Location of the project should be identified by State Route, highway reference marker(s), and the municipality and county in which work area is located. • In regard to State Environmental Quality Review (SEQR), indicate the type of action, the name of the Lead Agency, and what date the final determination was made, if available. • Signature of applicant and date. • Signature of second applicant, if any, and date. BACK OF APPLICATION • Check type of work that will be performed. • In the appropriate column, indicate total amount of permit fees (Include insurance fee for residential work) • Indicate type of performance security provided (bond, deposit, letter of credit), if required. • Indicate check number of deposit or bond number. Form PERM 33 (September 2023) Highway Work Permit Application for Non-Utility Work Instructions and Form (For Commercial Driveways, use Form PERM 33-COM) RESPONSIBILITIES OF PERMITTEE PURSUANT TO NON-UTILITY HIGHWAY WORK PERMITS NOTE: FAILURE TO OBTAIN A PERMIT OR FAILURE TO COMPLY WITH THE TERMS OF A PERMIT MAY RESULT IN THE DEPARTMENT HALTING THE ACTIVITY FOR WHICH A PERMIT IS REQUIRED UNTIL ADEQUATE CORRECTIONS HAVE BEEN MADE. 1. LIMITATIONS ON USE: The specific site identified in this Highway Work Permit, and only that site identified, will be available for use by Permittee only for the purpose stated in this Permit and only on the date(s) and for the duration designated in this permit. This Permit does not authorize any infringement of federal, state or local laws or regulations, is limited to the extent of the authority of NYSDOT and is transferable and assignable only with the written consent of the Commissioner of Transportation. The Commissioner reserves the right to modify fees and to revoke or annul the Permit at any time, at his/her discretion without a hearing or the necessity of showing cause. 2. CONDITIONS OF USE: NYSDOT makes no affirmation that the state-owned site used for the work has been designed, constructed, or maintained for the purpose of the conduct of the work. The Permittee assumes full responsibility for planning and conducting a safe and orderly project that does not expose workers or the public to any unreasonable hazards and that involves a minimal disruption of the normal uses of the state and local highway systems. It shall be the sole obligation of the Permittee to determine whether the site is suitable for the purpose of safely conducting the work. The Permittee assumes all responsibility for assuring that the use of the highway/property conforms to applicable requirements of law, including, but not limited to those set forth herein. Permittee agrees to assure compliance with New York Labor Law, industrial regulations, and OSHA regulations, and to assure the safety of all workers who will be engaged to do the permitted work. 3. INSURANCE COVERAGE: Permittee must have the insurance that is required for the type and extent of the work being performed. Permittee agrees to maintain liability insurance in full force and effect throughout the term of the highway work permit. Expiration of, or lack of, liability insurance automatically terminates the permit. To comply with this requirement, an applicant must furnish the Department with one of the following: • A completed Certificate of Insurance evidencing the required types and limits of insurance coverage, with New York State Department of Transportation named as an additional insured on the commercial general liability policy. An industry standard ACORD 25 form with an ACORD 855 Addendum is acceptable evidence of the required coverage. Certificate Holder should be indicated as New York State Department of Transportation, with the address of the issuing office. • A fully executed Undertaking Agreement may be provided by Municipalities, Public Utilities, Transportation Corporations, Public Service Corporations or Railroads, as an alternative to providing proof of commercial general liability the insurance. • Homeowners applying for a residential work permit (driveways, improvements or tree work) and performing their own work have the option to pay a $25 Insurance Fee, and waive the requirement to provide insurance coverage. Any contractor doing work on the homeowner’s behalf must be listed on the permit and provide satisfactory proof of insurance as set forth below. See “PERM 33 Submission Package Requirements” on page 4 for more detailed guidance on insurance coverage. 4. COMPENSATION AND DISABILITY INSURANCE COVERAGE: Permittee is required to have compensation insurance and disability coverage as noted in the provisions of the Worker's Compensation Law and Acts amendatory thereof for the entire period of the permit, or the permit will be invalid. Applicant must provide proof of coverage (Form C-105.2, U-26.3 or SI-12 for Worker’s Compensation, and DB-120.1 or DB-155 for Disability Benefits), or provide proof of exemption from this requirement (Form CE-200). 5. INDEMNIFICATION: Permittee agrees that, in addition to any protection afforded to NYSDOT under any available insurance, NYSDOT shall not be liable for any damage or injury to the Permittee, its agents, employees, or to any other person, or to any property, occurring on the site or in any way associated with Permittee’s activities or operations; whether undertaken by Permittee’s own forces or by contractor or other agents working on Permittee’s behalf. To the fullest extent permitted by law, the Permittee agrees to defend, indemnify and hold harmless the State of New York, NYSDOT and their agents from and against all claims, damages, losses and expenses, including but not limited to attorneys’ fees, arising out of any claim, including but not limited to claims for personal injuries, property damage or wrongful death and/or environmental claims, in any way associated with the Permittee’s activities or operations, no matter how caused. 6. NOTIFICATION: The following should be notified at the appropriate time as shown below: • Commissioner of Transportation, through the NYSDOT regional office, one week prior to commencing work. • Area gas distributors, 72 hours prior to any blasting. • Utility companies with facilities in work areas, before starting work (in accordance with Industrial Code 53). • Permission from utility company must be obtained before commencing work affecting the utilities' facilities. • NYSDOT regional signal maintenance shop, 3 days prior to starting work (traffic signal work). • NYSDOT regional office, at conclusion of work, and return original copy of permit to Resident Engineer. NOTIFICATION FOR ANNUAL PERMITS: Notify by phone, the Regional or Resident Engineer's Office, one week in advance, each time regular maintenance work is to be performed. In emergencies, notification by phone, fax or email should be made as soon as is practical, no later than the next business day. 7. SITE CARE AND RESTORATION: A bond, deposit (bank cashier’s check), or a Letter of Credit, in an amount designated by the Department of Transportation, may be required before a permit is issued, in order to guarantee restoration of the site to its original condition. A fully executed Undertaking Agreement may be accepted as an alternative security, where applicable. If the Department is obliged to restore the site to its original condition, the costs to the Department will be deducted from the amount of the permittee's deposit at the conclusion of the work. Costs in excess of the bond/deposit on file will be billed directly to the permittee. If permittee posts a Letter of Credit, the Department may elect to have a contractor restore the site, and issue a draft drawn against the Letter of Credit as payment. • Anyone working within state highway right-of-way must wear high visibility apparel and hard hat meeting ANSI Class 2 requirements. • No unnecessary obstruction is to be left on the pavement or the state highway right-of-way, or in such a position as to block warning signs during non-working hours. • No work shall be done to obstruct drainage or divert creeks, water courses or sluices onto the state highway right-of-way. • All false work must be removed and all excavations must be filled in and restored to the satisfaction of the Regional Maintenance Engineer. 8. COSTS INCURRED BY ISSUANCE OF THIS PERMIT: All costs beyond the limits of any liability insurance, surety deposits, etc. are the responsibility of the permittee. The State shall be held free of any costs incurred by the issuance of this permit, direct or indirect. 9. SUBMITTING WORK PLANS: The applicant will submit three (3) copies of work plans and/or maps as required by the Department. This shall include (but not limited to) such details as: measurements of driveways with relation to nearest property corner; location of existing and proposed poles, guide rail, signal equipment, trees or drainage structures; positions of guys supporting poles; a schedule of the number of poles and feet of excavation necessary for completion of work on the State right-of-way. A description of the proposed method of construction will be included. • Plan work with future adjustments in mind, as any relocation, replacement or removal of the installation authorized by this permit and made necessary by future highway maintenance, reconstruction or new construction, will be the responsibility of the permittee. • Driveway plans should be prepared in accordance with NYSDOT POLICY AND STANDARDS FOR ENTRANCES TO STATE HIGHWAYS. • The permittee must coordinate the work with any State construction being conducted. 10. TRAFFIC MAINTENANCE: A plan detailing how the permittee intends to maintain and protect traffic shall be submitted with work plans. Traffic shall be maintained on the highway in a safe manner during working and non-working hours until construction is completed. The permittee is responsible for traffic protection and maintenance, including adequate use of signs, barriers, and flag persons during working and non-working hours until construction is completed. All sketches will be stamped with "MAINTENANCE OF TRAFFIC SHALL BE IN CONFORMANCE WITH THE NATIONAL MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES.” 11. COST OF INSPECTION AND SUPERVISION: Prior to issuance of the Highway Work Permit, the permittee may be required to sign an INSPECTION PAYMENT AGREEMENT FOR HIGHWAY WORK PERMITS (FORM PERM 50) agreeing to the payment of construction inspection charges, based on the number of work days involved. In certain cases, the permittee may also be required to sign a PAYMENT AGREEMENT FOR HIGHWAY WORK PERMITS DESIGN REVIEW (FORM PERM 51) agreeing to design review charges, based on the number of work hours in which Department employees were engaged in design review activity. 12. SCOPE: • Areas Covered: Permits issued are for highways, bridges and culverts over which the New York State Department of Transportation has jurisdiction. (Local governments issue permits for highways under their jurisdiction.) Work locations must be approved by the Department. • Maintenance: Unless noted otherwise, applicant shall be fully responsible for the maintenance of all items installed and/or altered as shown on the approved permit plans and documents. Property owners having access to a state highway shall be fully responsible for the maintenance of their driveway in accordance with POLICY AND STANDARDS FOR ENTRANCES TO STATE HIGHWAYS. • Work Commencement: The Permittee shall have a copy of the permit available at the site during the construction period. Work should start within 30 days from validation date of permit or said permit may be revoked. 13. REPORTING ACCIDENTS: Permittee is required to report any accidents that occur during the course of the permit work to their insurance company, and to provide the Department with a copy of any such report. 14. COMPLETION OF PROJECT: Upon completion of the work within the State highway right-of-way authorized by the work permit, the person and his or its successors in interest shall be responsible for the maintenance and repair of such work or portion of such work as set forth within the Terms and Conditions of the Highway Work Permit. PERM 33 Submission Package Requirements Submit three (3) copies of the final submission package: Submission package must include the entire PERM 33 with all work plans and supporting documents, including the following (check all that apply): Stamped Final Plans – Submit in PDF file format on CD, with three (3) paper copies (1” = 50’), or as requested ACORD 25 - Certificate of Insurance, with NYSDOT named as Additional Insured (See line 3 below). ACORD 855 - New York Construction Certificate of Liability Insurance Addendum (See line 3 below). PERM 1, 2, 6 or 16 - Undertaking Agreement, if applicable (See line 4 below). PERM 36 - Attachment to Highway Work Permit – Consultant Inspection, if applicable PERM 44 - Surety Bond – Performance bond in Applicant’s name, or deposit (Bank cashier’s check required) PERM 50 – Inspection/Supervision Payment Agreement, if applicable Proof of Worker’s Compensation Insurance (Form C-105.2, U-26.3 or SI-12), or proof of exemption (Form CE-200) Proof of Disability Benefits Coverage (Form DB-120.1 or DB-155), or proof of exemption (Form CE-200) Permit Fee (Include $25 Insurance Fee for residential operations) Other (specify): Insurance Requirements 1) In most cases, Permittee must provide proof of Commercial General Liability insurance coverage with limits of liability not less than $1,000,000 per claim/occurrence, unless any of the following circumstances exist, in which case the limits of liability shall not be less than $5,000,000 per claim/occurrence: (a) The estimated value of permitted work in state right-of-way is $250,000 or more (see line 6 below); (b) The permitted work requires or includes the construction, alteration or maintenance of underground features at any depth five feet or more below grade; (c) The permitted work requires or includes the construction, alteration or maintenance of overhead features that include, but are not limited to, traffic signals, overhead sign structures, retaining walls or other grade separation structures. 2) Exceptions to the above liability limits include: (a) Annual maintenance permits require limits of liability not less than $5,000,000 per claim/occurrence; (b) Permits for vegetation control activities require limits of liability not less than $1,000,000 per claim/occurrence; (c) Residential driveway permits require limits of liability not less than $500,000 per claim/occurrence; and (d) Adopt-a-Highway permits are exempt. 3) ACORD 25 with ACORD 855 (New York Construction Addendum) shall be submitted as an acceptable proof of liability coverage. New York State Department of Transportation should be named as Additional Insured and as the Certificate Holder at the address of the issuing office. 4) Municipalities, public utilities, public authorities and railroads may elect to provide a fully executed Undertaking Agreement as a substitute for providing proof of insurance coverage, or any other financial security otherwise required. 5) Homeowners may pay a $25 Insurance Fee in lieu of providing proof of insurance, however any contractor performing on behalf of a homeowner and who is named on the permit must provide proof of insurance as outlined above. 6) When the estimated cost of work being performed in the right-of-way equals or exceeds $250,000, Permittee must additionally provide proof of a Protective Liability (OCP) insurance policy with a minimum liability limit of $1,000,000 per occurrence, with New York State Department of Transportation as Named Insured. For more information on insurance requirements, go to: www.dot.ny.gov/permits-insurance Permittee agrees to maintain liability insurance in full force and effect throughout the term of the highway work permit. Expiration of, or lack of, liability insurance coverage automatically terminates the permit. PERM 33 NON-UTILITY (9/23) SUBMIT THREE (3) COPIES STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION HIGHWAY WORK PERMIT APPLICATION FOR NON-UTILITY WORK For Joint application, name and address of Applicant 2 below: Name _______________________________________________ Address _____________________________________________ City ______________________ State ________ Zip __________ Applicant 2 Phone (_____)_________________________________ Application is hereby made for a highway work permit: Name ____CLEAN CROTON-ON-HUDSON (VILLAGE OF CROTON- ON-HUDSON CAC)____________________ Address ___1 VAN WYCK ST.____ City __CROTON-ON-HUDSON____ State __NY___ Zip 10520___Applicant Phone )914-271-4848 Applicant Email Addres_bhealy@crotononhudsonny.gov Applicant 2 Email Address ________________________________ RETURN PERMIT TO: (if different from Permittee) RETURN DEPOSIT/BOND TO: (if different from Permittee) Name _________________________________________________ Name _______________________________________________ Address _______________________________________________ Address _____________________________________________ City ______________________ State ________ Zip ____________ City ______________________ State ________ Zip __________ WILL OVERHEAD OR UNDERGROUND (5’+) OPERATIONS BE INVOLVED IN THE PROPOSED WORK? YES _____ NO _XX____ ATTACHED: Plans ____________ Specifications ____________ LOCATION: State Route: _9A________ Located Between Reference Markers _BALTIC AVE and MUNICPAL PLACE_______ City/Town/Village of __CROTON-ON-HUDSON___________________________ County of WESTCHESTER________________ SEQR REVIEW (select one) [ ] Type II [ ] Type I [ ] Unlisted LEAD AGENCY: ___________________________ DATE OF DETERMINATION: _________ Insurance (check one): _______ General Liability Insurance ______ Undertaking _______ Insurance Fee (residential operations only) NOTE: PERMIT IS ISSUED CONTINGENT UPON ALL LOCAL REQUIREMENTS BEING SATISFIED ACKNOWLEDGMENT: ON BEHALF OF THE APPLICANT, I HEREBY REQUEST A HIGHWAY WORK PERMIT, AND DO ACKNOWLEDGE AND AGREE TO THE RESPONSIBILITIES OF PERMITTEE AND THE OTHER OBLIGATIONS SET FORTH IN THIS PERMIT AND WARRANT COMPLIANCE THEREWITH. Applicant Signature ______________________________________________________ Date _____________________ Applicant 2 Signature _____________________________________________________ Date _____________________ DESCRIPTION OF PROPOSED WORK: _________________ ADOPT A HIGHWAY LITTER CLEANUP ALONG ROUTE 9A _________________________________________________________________________________________________________________________________ Estimated cost of work being performed in highway right-of-way: $ __0.00_____________________________________________ Anticipated duration of work: From ____________ to ____________ (applies to the operations indicated on the reverse side) Approval recommended by Resident Engineer ______________________________ Res No _________ Date __________ Approved by Regional Traffic Engineer _____________________________________ Reg No _________ Date __________ Emergency Contact _John Ealer cleancroton@johnealer.com_______________________________________________________ Emergency Phone (_310______) 403 5646_____________________________________________________ Operational Type and Description Permit Fee Insurance Fee Total Fees DRIVEWAYS 5a1 Residential Driveway (includes field entrances) 5a6 Temporary access road or street For Commercial Driveways and subdivisions streets, use form PERM 33-COM IMPROVEMENTS 5b1 Residential 5b2a Commercial- Sidewalk, curb paving, drainage, etc. 5b2b Commercial – Grade, seed, improve land contour, clear brush 5b2c Commercial – Resurface existing road or driveway 5b2d1 Annual resurfacing of roadways and driveways – PER COUNTY Number of counties: 5b2d2 Annual resurfacing of roadways and driveways – PER REGION TREE WORK 5c1 Residential 5c2a Commercial removal or planting 5c2b Commercial pruning, applying chemicals to stumps 5c3 Vegetation control for advertising signs – PER SIGN Number of Signs: MISCELLANEOUS CONSTRUCTION AND WORK OPERATIONS 5d1 Beautify ROW (civic groups only) N/C 5d2a Temporary signs, banners, décor (not-for-profit organizations) N/C 5d2b Temporary signs, banners, décor (Other organizations) 5d3 Traffic control signals 5d4 Warning and entrance signs 5d5 Miscellaneous – Requiring substantial review (describe below) 5d6 Miscellaneous (describe below) OTHER TYPES OF HIGHWAY WORK PERMITS Encroachment caused by DOT acquisition of property 7a1 Compulsory permit required for demolition requested by DOT N/C 7a2 Compulsory permit required for moving requested by DOT N/C 7b Improvement to meet Department standards N/C Miscellaneous (describe below) Adopt-a-Highway N/C Description of Miscellaneous Operation: PERFORMANCE SECURITY (Select one): Guarantee Deposit - Cash [ ] Performance Bond [ ] Letter of Credit [ ] Guarantee Deposit Amount: ___________________________ Guarantee Deposit Check Number or Bond Number _____________________________________________________ PERM 33 (9/23) REVERSE (To be completed by NYSDOT issuing office) Project Identification Number ______________________________ Highway Work Permit No. _______________________ State Highway (SH) Number _______________________________ Record ID Number _____________________________ If the following section of NYS Labor Law applies to the work to be performed under this permit, the application for and acceptance of this permit constitute the applicant’s/permittee’s agreement confirming the payment of wages as required by such section has been contractually mandated. New York Labor Law § 224-f. Workers on excavations. [Effective September 15, 2023] 1. For the purposes of this section: a. “Covered excavation project” shall mean construction work for which a permit may be issued to a contractor or subcontractor of a utility company by the state, a county or a municipality to use, excavate, or open a street. A “covered excavation project” shall exclude construction work for which a permit may be issued to a service provided as defined by subdivision twenty-three of section one thousand twenty-b of the public authorities’ law. b. “Department of jurisdiction” shall mean the department of the state, board or officer in the state, or municipal corporation or commission or board appointed pursuant to law, whose duty it is to issue a permit to a utility company, or its contractors or subcontractors, for a covered excavation project. c. “Fiscal officer” shall mean the commissioner; except for covered excavation projects performed pursuant to a permit issued by a city with a population in excess of one million in which case the “fiscal officer” shall be the comptroller or other analogous officer of such city. d. “Utility company” shall have the same meaning as subdivision twenty-three of section two of the public service law. 2. Each contractor or subcontractor to a utility company shall be required to pay not less than the prevailing rate of wage in the same trade or occupation in the locality within the state where such covered excavation project is situated to each laborer, worker, or mechanic in the employ of the contractor or subcontractor to a utility company, performing work on the project in accordance with sections two hundred twenty and two hundred twenty-b of this article. No permit shall be issued for a covered excavation project until an agreement confirming the payment of wages as required by this section has been contractually mandated and filed with the department of jurisdiction, and all permits issued after the effective date of this section shall include therein a copy of this section. 3. The enforcement of any covered excavation project pursuant to this section shall be subject to the requirements of sections two hundred twenty, two hundred twenty-a, two hundred twenty-b, two hundred twenty-three and two hundred twenty-four-b of this article and section two hundred twenty-seven of this chapter and within the jurisdiction of the fiscal officer; provided, however, nothing contained in this section shall be deemed to construe any covered excavation project as otherwise being considered public work pursuant to this article. 4. The fiscal officer may issue rules and regulations governing the provisions of this section. Any violation of this section shall be grounds for determinations and orders pursuant to section two hundred twenty-b of this article.