Fill - Free fillable Form 3113: ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS (County of Ulster) PDF form

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ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS

To: Commissioner of Public Works

Tel: 845-340-3100

Fax: 845-340-

3113

Department of Public Works

317 Shamrock Lane

Kingston, NY 12401

Permit # _____________________________ Date _____________________________

Application is hereby made by the undersigned ___________________________________________

_________________________________________________________________________________

for a permit to transport over Ulster County roads and bridges the following described vehicles of

dimensions which exceed the limitations provided for in Section 385 of the Vehicle & Traffic Law of

this State:

DIMENSIONS

DESCRIPTION OF VEHICLES* HEIGHT LENGTH WIDTH WEIGHT

___________________________ _____________ _____________ _____________ _____________

ORIGIN: _________________________________________________________________________________

DESTINATION: ___________________________________________________________________________

ROADS TO BE UTILIZED: __________________________________________________________________

DESIRED DATE (S) OF TRAVEL: ____________________________________________________________

TYPE OF PERMIT: CONDITIONAL ANNUAL

The COMPLETE ROUTE (all State, County, Town, Village, Local, etc. roads being traveled) and a LOAD

DIAGRAM showing the AXLE CONFIGURATION is required to be submitted with this permit application.

Applicant Information

Firm Name _________________________________________________________

Authorized Applicant Name (Please Print) _________________________________________________________

Authorized Signature _________________________________________________________

Title _________________________________________________________

Address _________________________________________________________

City _________________________________________________________

State, Zip _________________________________________________________

Phone _________________________________________________________

Fax _________________________________________________________

Email _________________________________________________________

* If additional listing space is required, attach supplemental sheet.

APPLICATION FOR SPECIAL HAULING PERMIT

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Permission is hereby granted to _________________________________________________________

_________________________ to operate, transport or move the vehicles and/or loads referred to on

Page 1 of this Application over the County Roads and Bridges and on dates specified pursuant to

the following Conditions and Restrictions:

1. This Permit shall not be assigned or transferred.

2. Notice shall be given by said Applicant to the Commissioner of Public Works at least 48

hours in advance of the date(s) when the transport involves a load which will present special

problems to the municipality, affect public utility lines, or required specialized escort

procedures.

3. The Applicant hereby agrees to indemnify and save harmless the County from all

suits actions or damages of every kind whatsoever which may arise from, or on account of,

the transport conducted under this Permit. General Liability Insurance for the protection of

the Applicant and the County will be maintained in such an amount and in such company

and in such case as the Commissioner may require.

4. The Commissioner reserves the right to revoke or cancel this Permit at any time should the

Applicant fail to comply with the terms and conditions.

5. Applicant’s approved copy of the Special Hauling Permit shall be in possession of the

transport parties.

6. Transport Criteria:

a) No moves shall be made on Sundays or Holidays, including business days before and

after Holidays.

b) All movements shall be limited to daylight hours, and only when weather and road

conditions are favorable.

c) Special arrangements or detour routes may be mandated when the County Road has a

designated load limit.

d) Bridge Load Limits shall be absolutely adhered to. No exceptions shall be made.

Violation of this clause shall result in immediate revocation of the Permit and subject

the Applicant to legal action as provided by applicable laws.

e) The Applicant shall be responsible for the inspection of the transport route to ascertain

limiting factors such as bridge clearances, bridge load limits, road gradients and

curvature, overhead line clearances and the like, prior to transport.

7. Proper traffic safety procedures, as set forth in the National MUTCD (Manual of

Uniform Traffic Control Devices), latest edition, and the NYS Supplement to the

MUTCD, shall be adhered to when loading, unloading, transporting or stopping within

the public highway corridor.

8. The Owner/Applicant is responsible to attain any additional required permits/permissions

including, but not limited to, applicable Federal, State and Local permissions.

9. Arrangements shall be made with local law enforcement agencies to provide, where required,

for the handling of motor vehicle traffic, the re-routing of traffic or similar emergencies that

may arise out of the exercise of this Permit.

APPLICATION FOR SPECIAL HAULING PERMIT

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10. The Permit Applicant shall be responsible for arrangements with the public utility

corporations to accommodate transport where overhead lines, guy wires and the like may

have to be disconnected, elevated or relocated.

11. Nothing herein contained shall be deemed to relieve the Applicant or limit its liability for

damages to County Roads, public utilities services or municipal services resulting from the

exercise of this Permit.

I hereby agree to the above “CONDITIONS AND RESTRICTIONS” as set forth in this SPECIAL

HAULING PERMIT.

_________________________________________ ____________________________________________

Authorized Applicant Name (Please Print) Authorized Applicant Signature Date

The COMPLETE ROUTE (all State, County, Town, Village, Local, etc. roads being traveled) and a LOAD

DIAGRAM showing the AXLE CONFIGURATION is required to be submitted with this permit application.

OFFICIAL USE ONLY

__________________

Initials

UCDPW Engineering

APPROVED

DISAPPROVED

NOT APPLICABLE

UCDPW Highway Operations

APPROVED

__________________

Initials

DISAPPROVED

________________________________________________

Commissioner, Ulster County Department of Public Works

County Ulster

State

of New York

Validated this __________ day of _________________________ 20__________

APPLICATION FOR SPECIAL HAULING PERMIT

ULSTER COUNTY

DEPARTMENT OF PUBLIC WORKS

317 Shamrock Lane

Kingston, NY 12401

ulstercountyny.gov

TEL (845) 340-3100 FAX (845) 340-3113

Special Hauling Permit Fee Schedule

Oversize

Single Use $ 10.00

Annual* $ 250.00

Overweight

Single Use $ 10.00

Annual* $ 250.00

Bridge Review** $ 50.00

* The Annual Permit covers oversized and overweight permits on County Roads without Bridges.

** Additional Fees are required for routes that require review from the Ulster County Engineering Department.

All checks are to be made payable to Ulster County Commissioner of Finance.

Submit all payments to: Ulster County Department of Public Works – Highway Department

317 Shamrock Lane

Kingston, NY 12401

Summary of Ulster County Insurance Requirements:

Item Numbers 1-3: See the following Sample Certificate of Insurance (Accord Form) for the

required minimum limits and the language required for the Additional Insured and Certificate Holder

Notes.

Item No. 4: See the following Part 1 and Part 2 lists of the appropriate acceptable forms for

Worker’s Compensation and Disability Benefits. Please note that the Accord Form is no

longer acceptable proof of NYS Workers’ Compensation and Disability Benefits Insurance

Coverage

Part 1: Acceptable forms for Workers’ Compensation: Provide one of the following.

C-105.2 or U-26.3 or GSI 105.2

Part 2: Acceptable forms for Disability Benefits: Provide one of the following.

DB 120.1 or DB-155

Starting December 1, 2008, ONLY applicants eligible for exemptions must file a new CE-200 for

each and every new or renewed permit, license or contract issued by a government agency. Each CE-

200 will specifically list the issuing government agency and the specific type of permit, license or

contract requested by the applicant. Applicants for building permits will also need to supply additional

information including identifying the specific job location and the estimated cost of the project.

Please ensure that the legal entity name on Form CE-200 exactly matches the legal entity name that is

applying for the permit, license or contract. Please also ensure that the applicant signs and dates Form

CE-200.

Each CE-200 will have a certificate number printed on it. Form CE-200s may be verified on the

Board's web site at www.wcb.state.ny.us.

The applicant attests under penalty of perjury that the information contained in the CE-200 is accurate

– the Board does not initially verify this information. However, Board staff may investigate applicants

filing Form CE-200.

** Be sure to forward the following pages to your insurance company to ensure the proper

insurance coverage to is submitted Ulster County.

DATE MM/DD/YY

LTR

TYP

E OF INSURANCE POLICY NUMBER

POLICY EFFECTIVE

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY)

GENERAL AGGREGATE 1,000,000.00$

ITEM 1

COMMERCIAL GENERAL LIABILITY

PRODUCTS-COMP/OP AGG 1,000,000.00$

CLAIMS MADE OCCUR

PERSONAL &ADV INJURY 1,000,000.00$

OWNER & CONTRACTOR'S PROT

EACH OCCURRENCE 1,000,000.00$

__________________________ FIRE DAMAGE Any one fire 50,000.00$

MED EXP Any one person 5,000.00$

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OW NED AUTOS

__________________________

AUTO ONLY-EACH ACCIDENT -$

ANY AUTO

OTHER THAN AUTO ONLY -$

____________________________

EACH ACCIDENT -$

AGGREGATE -$

EACH OCCURRENCE -$

UMBRELLA FORM

AGGREGATE -$

OTHER THAN UMBRELLA FORM

EL EACH ACCIDENT $ -

EL DISEASE-POLICY LIMIT $ -

EL DISEASE-EA EMPLOYEE $ -

OTHER

ITEM 2

ITEM 3

ACORD

CERTIFICATE OF LIABILITY INSURANCE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIR

ATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL

10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,

BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE MO OBLIGATION OR LIABILITY

OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES

County of Ulster

PO Box 1800

244 Fair Street

Kingston, NY 12402

ACORD CORPORATION 1983

ACORD 25-S (1/95)

BODILY INJURY

Per accident:

PROPERTY DAMAGE -$

COMBINED SINGLE LIMIT

BODILY INJURY

Per person:

GENERAL LIABILITY

AUTOMOBILE LIABILITY

EXCESS LIABILITY

THE PROPRIETOR PARTNERS/

EXECUTIVE OFFICERS ARE:

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

Ulster County, PO Box 1800, 244 Fair Street, Kigston, NY 12402 is named as an

additional insured with respect to work performed by the insured.

DESCRIPTION OF OPERATIONS; LOCATIONS; VEHICLES; SPECIAL ITEMS

CANCELLATIONCERTIFICATE HOLDER

LIMITS

COVERAGE'S

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD

INDICATED, NOTW ITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERIN IS SUBJECT TO ALL THE TERMS,

EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

GARAGE LIABILITY

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION

ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE

HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR

ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.

COMPANIES AFFORDING COVERAGE

PRODUCER

COMPANY

INSURED

COMPANY

INCL

EXCL

Item No. 4: Workers Compensation and Disability Benefits

PART 1:

WORKERS’ COMPENSATION REQUIREMENTS UNDER WORKERS’ COMPENSATION

LAW §57

To comply with coverage provisions of the Workers’ Compensation Law (“WCL”), businesses must:

A) be legally exempt from obtaining workers’ compensation insurance coverage; or

B) obtain such coverage from insurance carriers; or

C) be a Board-approved self-insured employer or participate in an authorized group self-

insurance plan.

To assist State and municipal entities in enforcing WCL Section 57, businesses requesting permits or

seeking to enter into contracts MUST provide ONE of the following forms to the government entity

issuing the permit or entering into a contract:

A) C-105.2 -- Certificate of Workers’ Compensation Insurance (the business’s insurance carrier will send this

form to the government entity upon request) PLEASE NOTE: The State Insurance Fund provides its

own version of this form, the U-26.3; OR

B) GSI-105.2 -- Certificate of Participation in Worker’s Compensation Group Self-Insurance (the business’s

Group Self-Insurance Administrator will send this form to the government entity upon request), OR

Certificate of Workers’ Compensation Self-Insurance (the business calls the Board’s Self-Insurance

Office at 518-402-0247).

PART 2:

DISABILITY BENEFITS REQUIREMENTS UNDER WORKERS’ COMPENSATION LAW

§220(8)

To comply with coverage provisions of the WCL regarding disability benefits, businesses may:

A) be legally exempt from obtaining disability benefits insurance coverage; or

B) obtain such coverage from insurance carriers; or

C) be a Board-approved self-insured employer.

Accordingly, to assist State and municipal entities in enforcing WCL Section 220(8), businesses

requesting permits or seeking to enter into contracts MUST provide ONE of the following forms to the

entity issuing the permit or entering into a contract:

A) DB-120.1 -- Certificate of Disability Benefits Insurance (the business’s insurance carrier will send this

form to the government entity upon request); OR

B) DB-155 -- Certificate of Disability Benefits Self-Insurance (the business calls the Board’s Self-

Insurance Office at 518-402-0247).

INSTRUCTIONS FOR OBTAINING FORM CE-200

The CE-200 in now an on-line application. Please remember that applicants are submitting the CE-200

under penalty of perjury, a felony carrying a penalty of four years jail time. Accordingly, all statements

on the CE-200 must be true.

Applicants may access the CE-200 application on the Board’s Website: www.wcb.ny.gov

1. Click on the button entitled “WC/WB Exemption Forms CE-200” (In bright yellow letters).

2. Click on the Request for WC/WB Exemption (Form CE-200).

3. Click the gray button on the bottom (Select to access web –based Application).

4. Applicants should create their own PIN number.

5. Follow the rest of the prompts.

It should take about 5 minutes to fill out the first time. Applicants are required to print, sign and

date Form CE-200 and send it to the Government Agency issuing their permit, license, or

contract from.

If the applicant is having difficulty in printing the CE-200, please call the Board’s CE-200 Hotline at

866-546-9322, then press 1, and then press 3 and leave a voice message with the certificate number,

the name of the business and a contact number. The CE-200 will be sent to the business address on the

CE-200 within one business day.

Fill Online, Printable, Fillable, Blank Form 3113: ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS (County of Ulster) Form

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Fillable Form 3113: ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS (County of Ulster)

Fill Online, Printable, Fillable, Blank Form 3113: ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS (County of Ulster) Form

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