Fill - Free fillable 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 _____________________________

TO: Commissioner of Public Works

County of Ulster

Application is hereby made for a Special Event Permit for access to road(s) on the County Road System.

Applicant ________________________________________________________________________

Address ________________________________________________________________________

________________________________________________________________________

Telephone Daytime _______________ Emergency _______________ Fax _______________

Email ________________________________________________________________________

Purpose of Event ________________________________________________________________________

Date of Event ________________________________________________________________________

County Road(s) to be Utilized ____________________________________________________

If a permit is granted, I hereby agree to conform to all the conditions and restrictions forming a part of

this permit and to conform to all local ordinances, if any, and to conform to the provisions as set forth

in the Federal and New York State MUTCD (Manual of Uniform Traffic Control Devices).

APPLICANT' S NAME (Please Print) TITLE DATE

APPLICANT'S SIGNATURE

OFFICIAL USE ONLY

Permission is hereby granted to applicant.

A Certificate of General Liability (bodily injury/property damage) Insurance, with “Additional

Insured” endorsement, shall be on file at the Office of the Commissioner of Public Works and be in

compliance with the Department’s current insurance directives.

Signature _____________________________________________ Date ____________________

COMMISSIONER OF PUBLIC WORKS

Signature _____________________________________________ Date ____________________

UCDPW REVIEWER

APPLICATION FOR SPECIAL EVENT PERMIT

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CONDITIONS & RESTRICTIONS

THE FOREGOING PERMIT IS GRANTED SUBJECT TO THE FOLLOWING CONDITIONS:

1. This permit shall not be assigned or transferred except with the written consent of the County

Commissioner.

2. 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

event 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 County Commissioner may require. The County of Ulster shall be named as “Additional

Insured” on the policy provided.

3. A map shall be provided if the event is to take place on multiple roads, highlighting the affected

road segments.

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

the applicant fail to comply with the terms and conditions herein prescribed.

5. Applicant’s approved copy of this permit shall be in possession of the parties actually involved.

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

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

7. It is mandated that the local fire company(s) as well as the emergency medical service receive

prior written notification of the Special Event in order to respond efficiently to non-permit

related emergencies as such may occur during the duration of the permit activity.

Copies of such notification shall be provided to the Commissioner of Public Works prior to

validation of the permit.

8. This permit is subject to any and all constraints, which may be predicated by the Commissioner

of Public Works and/or local municipality.

9. Arrangements shall be made with local law enforcement agencies to provide, during the period

of such Special Event for the handling of pedestrian and motor vehicle traffic, the re-routing of

traffic, caring for emergencies and other related needs.

10. The applicant hereby agrees to clean up any debris along the County Highway System in the

vicinity of the specified locations arising out of or as a result of the activity under this permit.

11. No County Road closures will take place during this event and none will be permitted.

Refer to Schedule A for Special Conditions if box is checked.

I HEREBY

AGREE TO THE ABOVE CONDITIONS AND RESTRICTIONS.

_________________________________________ ____________________________________________

Authorized Applicant Name (Please Print) Authorized Applicant Signature Date

APPLICATION FOR SPECIAL EVENT PERMIT

Summary of Ulster County Insurance Requirements:

Item Numbers 1-3: See the attached 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.

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