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

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ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS (County of Ulster)

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U.S.A. forms for County of Ulster

BROWSE COUNTY OF ULSTER (NY) FORMS

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Page 1
ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS
To: Commissioner of Public Works
Department of Public Works
317 Shamrock Lane
Kingston, NY 12401
Application is hereby made for permission under Section 136 of the Highway Law, to enter upon and construct the following facilities
on the following named Ulster County Road:
Permit #__________________ Permit Type______________________
(Subdivision Road, Major Driveway Access, Utility, etc.)
Owner / Applicant Information Contractor Information
Name Name
Contact Contact
Address Address
City City
State, Zip State, Zip
Phone
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Phone
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Fax Fax
Cell phone Cell phone
Email ______________________________________ Email ______________________________________
Location
Street (County Road #) _____________________________ Segment(Official use only) ______________________________
Address ________________________________________________________________________________________________
Location ________________________________________________________________________________________________
Purpose ________________________________________________________________________________________________
Special Conditions _________________________________________________________________________________________
Town, Section-Block-Lot # ______________________________________________, ____________-____________-____________
In County Pavement Yes No Size _______________ Depth __________________
If permit is granted, I hereby agree to all the conditions and restrictions forming a part of this permit and to restore to its original
condition, any portion of the road, shoulders or drainage that may be disturbed.
IF, AFTER SUFFICIENT TIME AS DETERMINED BY THE COMMISSIONER OF PUBLIC WORKS, OR THEIR
REPRESENTATIVE, THE WORK TO BE PERFORMED UNDER THIS PERMIT IS NOT COMPLETED, SAID PERMIT
SHALL BE CANCELLED AND THE DEPOSIT WILL BE FORFEITED.
__________________________________________________________________________________________________________
(Owner / Applicant Signature) (Title) (Date)
_________________________________________________________________________________________
Permission is hereby granted to perform work enumerated above, subject to attached conditions and restriction. A Certified Check
made payable to the ULSTER COUNTY COMMISSIONER OF FINANCE, is to be deposited as a guarantee that the work shall be
completed in compliance with this permit and that the road will be restored to its original condition at the expense of the
owner/applicant.
Signature: _________________________________________ Date:____________
For: COMMISSIONER OF PUBLIC WORKS
Signature: _________________________________________ Date:____________
UCDPW REVIEWER
OFFICIAL USE ONLY
Date Submitted___________________ Temp. Patch Date________________________ App. Ck.#_________________________
Date Issued______________________ Temp. Patch Contractor__________________ Insp. Ck.#_________________________
Start Date_______________________ Perm. Patch Date________________________ Bond $____________________________
Expiration Perm. Patch Contractor______________________________________________________
Reviewers Initial_________________ Review Status: Closed Pending Public Received Technical
Date Reviewed___________________ (circle one) Decision Hearing Review
Decision Date____________________ Decision: Approved Conditional Denied Withdrawal
(circle one) Approval
Tel: 845-340-3100 APPLICATION FOR
A C
OUNTY
ROAD PERMIT
Fax: 845-340-3113
Rev. 2019
OWNER / APPLICANT SHALL FURNISH FULL INFORMATION AS TO THE NATURE OF THE WORK
TO BE UNDERTAKEN, LOCATION, DETAILS OF STRUCTURE(S) INVOLVED, ETC., AND SHALL
ATTACH A SKETCH SHOWING LOCATION AND AREA AFFECTED.
Two (2) original copies of this application are to be executed by Owner / Applicant with approving signatures.
When approved by County Commissioner, one copy will be returned to Owner / Applicant.
A PROPERLY EXCECUTED COPY OF THIS PERMIT MUST ALWAYS BE AVAILABLE ON THE WORK
UNDERTAKEN, TO BE SUBMITTED TO THE ENGINEER AT HIS REQUEST.
Conditions and Restrictions
THE FORGOING PERMIT IS GRANTED SUBJECT TO THE FOLLOWING GENERAL CONDITIONS,
AND SUBJECT TO THE “SPECIFICATIONS AND RESTRICTIONS GOVERNING WORK DONE UNDER
PERMITS”.
1. This permit shall not be assigned or transferred except with the written consent of the County
Commissioner.
2. The work authorized by this permit shall be done to the complete satisfaction of the County
Commissioner or his representative. In replacement of pavements, the Standard County
Specifications therefore shall be followed.
3. Notice shall be given by said Application to the County Commissioner at least 48 hours in advance of the
date when the work is to begin.
4. The Owner / Applicant hereby agrees to indemnify and save harmless the County from all suits,
actions of damages of every kind whatsoever which may arise from or on account of the work to be done under
this permit. General Liability Insurance for the protection of the Owner / Applicant and the County will be
maintained in such an amount and in such company and in such case as the County Commissioner may require.
5. The Owner / Applicant agrees, in consideration of this permit, that any present or future injury to or
disturbance of the road, its pavement, shoulders, its slopes or gutters, caused by the work proposed under
this permit, shall be repaired by the Owner / Applicant at his/her own expense and to the complete
satisfaction of the County Commissioner.
6. The County Commissioner reserves the right to revoke or cancel this permit at any time should the Owner /
Applicant fail to comply with the terms and conditions herein prescribed.
7. Owner / Applicant’s approved copy of this permit shall be in possession of the parties actually doing the
work. It must be furnished on demand, to the County Commissioner or his representative.
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. Traffic shall be maintained on this section of the road by the Owner / Applicant during the life of this permit in
accordance with the National Manual of Uniform Traffic Control Devices, latest Edition.
10. The Owner / Applicant hereby certifies that he has secured compensation for the benefit of, and will keep
insured during the performance of the above described work, such employees as are required to be insured by
the provisions of Chapter 41 of the Laws of 1914 and Acts amendatory thereof, known as the Workmen’s
Compensation Law.
11. If necessity arises in future, because of this work on the highway, to make repairs pertaining to this permit,
said work shall be done at the expense of the Owner / Applicant.
12. The County shall not be held responsible for any damage/injury due to poor sight distances that may exist.
Refer to Schedule A for Special Conditions if Box is Checked.
I HEREWITH AGREE TO THE ABOVE “CONDITIONS AND RESTRICTIONS”
______________________________________ ______________________________________
DATE (OWNER / APPLICANT)
Page 2
Rev. 2019
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ULSTER COUNTY DEPARTMENT OF PUBLIC WORKS (County of Ulster)

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Completed 22 January 2021

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