Fillable Temporary Use Of State Right Of Way

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Temporary Use Of State Right Of Way

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BROWSE TOWN OF HUNTINGTON (NY) FORMS

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PERM 33-g (6/20) Page 1 of 5
State of New York
Department of Transportation
PERM 33-g
Application
for COVID-19 Recovery Temporary Use Permit
for the Use of
State Highway/NYSDOT Property
A PERM 33-g is required when a COVID-19 reopening-related event/activity is planned to take place
on state highway right-of-way, involving the alternate temporary use (not to exceed 120-days) of
State-owned sidewalks, parking areas, highway shoulders, travel lane or any other state right-of-way
for the direct purposes of facilitating social distancing and other reopening phase requirements.
PERM 33-g (6/20)
Page 2 of 5
PERM 33-g NEW YORK STATE DEPARTMENT OF TRANSPORTATION (Application Form)
APPLICATION FOR COVID-19 RECOVERY TEMPORARY USE
Complete this application form and a COVID -19 Temporary Use Permits Operation and Safety Plan in this
packet and submit the original prior to the event date to NYSDOT for approval. Also keep a copy for your
records. Upon approval, one copy will be returned to you that will serve as permission for the Temporary Use.
Return the application to:
New York State Department of Transportation - Regional Traffic Engineer, NYSDOT Region
1. Proposed Temporary Use:
Date(s) - (Cannot exceed 120 days to qualify for
Time(s)
waiver of fair market value fees under Executive Order)
2. Type of Temporary Use Event:
Commercial Activity
Associated with
Temporary Use?
3. Location (specify highways by route number and/or street name, by municipality):
_________________________________________________________________________________________
_________________________________________________________________________________________
4. Applicant Information:
___________________________________________
Authorized Representative Name & Title
______________________________________________
Land Line Phone - (include area codes) - Cell Phone
_____________________________________________
Email Address (if different from Applicant)
_____________________________________________
Web Site Address (if appropriate)
______________________________________________
Applicant (city/town/village/county or business entity)
Mailing Address Line 2
Email Address
Acknowledgment On behalf of the applicant I hereby request permission for a Temporary Use, and do acknowledge and agree to
the terms and conditions and obligations set forth in this application and warrant compliance therewith. The attached documents are also
made a part hereof and attached hereto:
_________________________________________
Applicant or Authorized Representative’s Signature
_________________________________________
Date Signed
(Click all that apply )
Description of Proposed Temporary Special Use
I am the Applicant noted directly above. It is my intent, to sign this
document electronically by placing a facsimile or image of my hand-
written signature above. I understand that my signing and
submitting this record/document in this fashion is the legal equivalent of
having placed my handwritten signature on the submitted document.
Date Received by NYSDOT
Application Approved by:
________________________________________
NYSDOT Regional Traffic Engineer Signature
_________________________________________
Date Signed
Date of FHWA waiver (if needed)
Changes to Parking?
Changes to Pedestrian Flow?
Vehicular Traffic - Restrictions or Rerouting?
Other
Mailing Address Line 1
click to sign
signature
click to edit
click to sign
signature
click to edit
PERM 33-g (6/20) Page 3 of 5
OPERATION AND SAFETY PLAN CHECKLIST
Please supply the following information or note as “Not Applicable.”
Event Map and Description – Some events are confined to a specific site along a highway (e.g.
festival), while others may extend for a significant distance (e.g. parades, races). Where appropriate,
please show on a map the event location, start and finish lines, direction of travel, railroad crossings,
and detour (if present). For the description, include start and ending times and the type of event.
COVID -19 Temporary Use Permits Operation and Safety Plan – Applicants must provide
an Operation and Safety Plan that comports with the Covid-19 Temporary Use Guidelines
The Operation and Safety Plan must detail how the Applicant intends to (1) promote safety and (2)
minimize the disruption of traffic. To the extent of any closure on the state highway or the disruption
of the movement of traffic proceeding along (e.g. lane and shoulder closures), entering, or crossing
a state highway for a period more than ten minutes, the Applicant shall provide and maintain a
signed detour or police officers to direct traffic.
Applicant is sponsor responsible for: insurance, social distancing plans, speed and other law
enforcement, community and emergency services outreach, ADA requirements, and the
construction and removal of all associated improvements.
PERM 33-g (6/20) Page 4 of 5
Responsibilities of Applicant
1. Limitations on Use. The specific site identified in this permission, and only that portion identified, will be available for use by
Applicant only for the purpose stated in this permission and only on the date(s) and for the duration designated in this permission.
The authorization herein shall be only for the actual duration of the event.
2. Fee for Use - State Highways not acquired using federal funds or no commercial activity- No fee required
Fee for Use - State Highways acquired using federal funds involving commercial activity - FHWA approval of waiver of fee
based upon fair market value of use required.
3. Conditions of Use. NYSDOT makes no affirmation that the state-owned site to be used for the event has been designed,
constructed, or maintained for the purpose of the conduct of the event. The Applicant assumes full responsibility for planning and
conducting a safe and orderly event that does not expose participants 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 Applicant to
determine whether the site is suitable for the purpose of safely conducting the event. The Applicant 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.
4. Indemnification: NYSDOT shall not be liable for any damage or injury to the Applicant,
employees, event organizers and volunteers, or participants, or any other person, or to any property, occurring on the site covered
by this permission or any part thereof associated in any way with Applicant’s use of the site. To the fullest extent permitted by law,
the Applicant 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 for personal injuries,
property damage or wrongful death associated in any way with the Applicant’s or participants’ use of the involved site(s,) or in any
way related to the event, no matter how caused. Where the applicant is a municipality, proof of insurances is not required.
However municipal agrees to take responsibility for its operations under this permit. Municipalities are encouraged to have a
PERM 1 Undertaking on file with NYSDOT Insurance Requirements.
5. Insurance: Non-municipal Applicants shall provide NYSDOT with proof of insurance prior to the installation of any temporary
traffic control devices or the commencement of the event, i.e. a certificate of insurance is required to maintain and provide proof
that it has, in full force and effect, the following insurance coverages:
(a) Workers’ Compensation and Disability Insurance. As required by State Finance Law §142, the Applicant shall maintain in force
workers’ compensation insurance for all employees. The Applicant shall also maintain disability insurance as required by the
Disability Benefits Law of the State of New York.
b) Commercial General Liability Insurance. The Applicant shall maintain an occurrence form commercial general liability policy or
policies insuring against liability arising from premises (including loss of use thereof), personal injury or death, advertising injury,
liability insured under an insured contract (including the tort liability of another assumed in a business contract) occurring on or in
any way related to the premises or occasioned by reason of the operations of the Applicant. Such coverage shall be written on an
ISO occurrence form CG 00 01 12 07 (or a form that provides equivalent coverage) in an amount of not less than ONE MILLION
DOLLARS ($1,000,000.00) per occurrence and not less than TWO MILLION DOLLARS ($2,000,000.00) aggregate. This insurance
must be endorsed to provide coverage to “The State of New York/New York State Department of Transportation, any municipality in
which the event is conducted, and any governmental entity whose facilities are affected by the event, or any of their employees or
agents working for or on the event,” using ISO form CG 20 10 07 04 or a form that provides equivalent coverage.
(c) Automobile Insurance (applicable where automobiles or other vehicles will be used in relation to the event). The Applicant shall
maintain a commercial or other automobile policy or policies insuring against liability for bodily injury, death, or damage to property
and other mandatory coverages, relating to the use, operation, loading or unloading of any of Applicant’s automobiles (including
owned, hired and non-owned vehicles) on and around the site/event. Coverage shall be in an amount of not less than ONE
MILLION DOLLARS ($1,000,000.00) each accident.
(d) Umbrella or Excess Liability Insurance. The Applicant shall maintain an occurrence form umbrella liability policy or policies
insuring against liability arising from premises (including loss of use thereof), operations, personal injury and advertising injury, and
liability insured under an insured contract (including the tort liability of another assumed in a business contract) occurring on or in
any way related to the premises or occasioned by reason of the operations of the Applicant as described above. Such coverage
shall be written on an ISO occurrence form CU 00 01 12 07 or a form that provides equivalent coverage. In the event that umbrella
coverage is unavailable, equivalent excess coverage may be substituted. The minimum required limits for the umbrella/excess
coverage shall be sufficient to provide a total of not less than FIVE MILLION DOLLARS ($5,000,000.00) per occurrence/ aggregate.
6. Termination of the Permission. NYSDOT shall have the right, in its sole discretion, at any time to terminate this permission, or any
portion thereof, should it be necessary due to operations or other reasonable need of NYSDOT, by giving written notice of termination of
the permission. Any termination by NYSDOT shall in no way constitute or be deemed a breach of this Permission and no liability shall
be incurred by or arise against NYSDOT, its agents and employees for loss of profits or any other damages.
7. Applicant’s Use of the Highway/Property. The Applicant shall exercise due care in its use of the site and shall upon the expiration,
termination, or cancellation of the issued permission, surrender the site in as good a condition as on the effective date of this
permission, ordinary wear and tear excepted. The Applicant shall designate a representative to conduct both a pre-event and
post-event field review of the event course with the NYSDOT Resident Engineer(s) to determine what damage may or may not
have resulted from the event. The Resident Engineer is given the authority to determine if any of the post-event damage is required to
be repaired.
8. Agency’s Representative. The Commissioner of the NYS Department of Transportation, or his/her designee, shall be, and hereby
is authorized to act for and on behalf of NYSDOT.
9. Reporting Requirements. The Permittee agrees to notify the Agency’s representative about any hazardous or unsafe conditions
and about any accidents that occur during the event immediately upon the discovery of such condition or accident.
10. Legal. The privilege granted by this permission 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 permission at any time, at his/her
discretion without a hearing or the necessity of showing cause.
PERM 33-g (6/20) Page 5 of 5
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Temporary Use Of State Right Of Way

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Completed 13 July 2020

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