Form PERM75 "Consolidated Application and Permit for Highway Work and Use & Occupancy for Fiber Optic Facilities and Supporting Infrastructure" - New York

What Is Form PERM75?

This is a legal form that was released by the New York State Department of Transportation - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the New York State Department of Transportation;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PERM75 by clicking the link below or browse more documents and templates provided by the New York State Department of Transportation.

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Form PERM 75
Consolidated Application and Permit for Highway Work and Use & Occupancy
For Fiber Optic Facilities and Supporting Infrastructure
Effective April 1, 2020
INSTRUCTIONS FOR COMPLETING THE CONSOLIDATED APPLICATION
This is a fillable form application, which can be signed and submitted electronically. If submitting hard copy, you must
submit three (3) copies of this application, all work plans and all other supporting documents, as required.
At 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.
The consolidated Highway Work Permit and Use & Occupancy Permit Application will be submitted to the Regional Permit
Office to initiate review. The Regional Permit Engineer will conduct a technical review of the submitted work plans, while
Regional Right of Way staff will calculate fees and other specific items relating to the Use & Occupancy Agreement. There
are Highway Work Permit fees in addition to any annual fees for Use & Occupancy.
THIS APPLICATION WILL BE REJECTED IF INCOMPLETE.
A Use & Occupancy Permit will be prepared by the Regional Right of Way office and delivered to the applicant. The
annual fee for Use & Occupancy will be assessed by the Office of Right of Way, using the Department’s Use and
Occupancy Fee Schedule for Fiber Optic Installations. The fee schedule may be found at:
https://www.dot.ny.gov/divisions/engineering/real-estate/Fiber Optic
The applicant will execute three duplicate original permits and return them to the Office of Right of Way for execution by its
Director. Original signatures are required on all permits to perform the work in the Right-of-Way (electronic signatures will
also t be accepted). One original agreement shall be returned to the applicant/Permittee, one original to the Regional
Permit Office and one retained by the Office of Right of Way.
Once the Use & Occupancy Permit is executed and the Fiber Optic fee Security Deposit is received, Regional Permit
Engineer may issue the Highway Work Permit, once all requirements are satisfied and Highway Work Permit fee is paid,
to allow construction to commence.
A USE & OCCUPANCY PERMIT MUST BE EXECUTED BEFORE
A HIGHWAY WORK PERMIT CAN BE APPROVED FOR CONSTRUCTION
FRONT OF APPLICATION (PAGE 10)
Permittee names, addresses, phone numbers, tax ID numbers and email addresses. If there are additional applicants,
provide joint applicant contact information, on a separate sheet (up to three additional applicants). Provide name and
phone number(s) of emergency contact person. Note that the Permittee for the Use and Occupancy Permit may be
different from the Permittee for the Highway Work Permit.
Provide an estimate of the cost of work being performed in the state highway right-of-way.
Indicate the anticipated duration of work to be performed with starting and ending dates.
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.
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Form PERM 75
Consolidated Application and Permit for Highway Work and Use & Occupancy
For Fiber Optic Facilities and Supporting Infrastructure
Effective April 1, 2020
INSTRUCTIONS FOR COMPLETING THE CONSOLIDATED APPLICATION
This is a fillable form application, which can be signed and submitted electronically. If submitting hard copy, you must
submit three (3) copies of this application, all work plans and all other supporting documents, as required.
At 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.
The consolidated Highway Work Permit and Use & Occupancy Permit Application will be submitted to the Regional Permit
Office to initiate review. The Regional Permit Engineer will conduct a technical review of the submitted work plans, while
Regional Right of Way staff will calculate fees and other specific items relating to the Use & Occupancy Agreement. There
are Highway Work Permit fees in addition to any annual fees for Use & Occupancy.
THIS APPLICATION WILL BE REJECTED IF INCOMPLETE.
A Use & Occupancy Permit will be prepared by the Regional Right of Way office and delivered to the applicant. The
annual fee for Use & Occupancy will be assessed by the Office of Right of Way, using the Department’s Use and
Occupancy Fee Schedule for Fiber Optic Installations. The fee schedule may be found at:
https://www.dot.ny.gov/divisions/engineering/real-estate/Fiber Optic
The applicant will execute three duplicate original permits and return them to the Office of Right of Way for execution by its
Director. Original signatures are required on all permits to perform the work in the Right-of-Way (electronic signatures will
also t be accepted). One original agreement shall be returned to the applicant/Permittee, one original to the Regional
Permit Office and one retained by the Office of Right of Way.
Once the Use & Occupancy Permit is executed and the Fiber Optic fee Security Deposit is received, Regional Permit
Engineer may issue the Highway Work Permit, once all requirements are satisfied and Highway Work Permit fee is paid,
to allow construction to commence.
A USE & OCCUPANCY PERMIT MUST BE EXECUTED BEFORE
A HIGHWAY WORK PERMIT CAN BE APPROVED FOR CONSTRUCTION
FRONT OF APPLICATION (PAGE 10)
Permittee names, addresses, phone numbers, tax ID numbers and email addresses. If there are additional applicants,
provide joint applicant contact information, on a separate sheet (up to three additional applicants). Provide name and
phone number(s) of emergency contact person. Note that the Permittee for the Use and Occupancy Permit may be
different from the Permittee for the Highway Work Permit.
Provide an estimate of the cost of work being performed in the state highway right-of-way.
Indicate the anticipated duration of work to be performed with starting and ending dates.
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.
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Plans and specifications should accompany this application for any work within the state highway right-of-way.
Location of the project should be identified by State Route, reference marker(s), and municipality/county.
Dated signature of applicant, as well as dated signature of any additional applicants.
BACK OF APPLICATION (PAGE 11)
Check type of work that will be performed.
In the appropriate column, indicate total amount of Highway Work Permit fees.
Indicate Utility Charge Account Number, if applicable
Indicate type of performance security provided (bond, deposit, letter of credit), if required.
INSTALLATION SEGMENT CHART
An installation segment chart in the format provided, must accompany each application. The chart will detail each
proposed fiber optic segment.
Fiber optic segments to be installed on county and local highways should not be included in the fiber cable
segments to be permitted. There are no state-assessed permit fees for county or local highway occupancies.
It is the responsibility of the applicant to delineate the permit area and right of way boundaries. If a fiber optic
installation is later found to be outside of the state highway right of way, the State will not reimburse permit fees
paid.
AERIAL IMAGE DEPICTIONS
In addition to the plans submitted for the Highway Work Permit application, a clearly legible aerial image depiction(s) of
the installations is required and will, in most cases, serve as an illustration of the permit area and its use (permit sketch).
Multiple images are to be submitted where necessary for a property scaled, detailed depiction. These aerial depictions
must include:
Delineations of each fiber optic longitudinal segment
Delineation of each highway right of way transverse crossing
Number of fiber optic cables
Number of fiber optic strands per cable
Segment lengths in linear feet
Distance of fiber from edge of roadway
Depth of burial of fiber in relation to any other utilities or culverts in the vicinity
Method of installation for each segment shown on the plans
Highway mile marker references
State highways and cross streets labeled
Indication of aerial versus underground installations
Filled conduit and additional empty conduit to be installed (and/or empty micro ducts)
A north arrow
A map scale
FIBER FEE SECURITY DEPOSIT
A security deposit of five percent (5%) of the annual permit fee will be due and collected at the time of the submission of
the permit signed by applicant, with a minimum deposit of $200.
INSURANCE
Proof of Insurance as described below.
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RESPONSIBILITIES OF PERMITTEE
PURSUANT TO HIGHWAY WORK PERMIT AND USE & OCCUPANCY PERMIT
FOR FIBER OPTIC FACILITIES AND SUPPORTING INFRASTRUCTURE
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.
A. HIGHWAY WORK PERMIT
1. LIMITATIONS ON USE: The specific site identified in this 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 and
occupancy 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 insurance.
See PERM 75 Submission Package Requirements below 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
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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. NOTIFICATIONS: 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 MAINTENANCE PERMITS: (1) Except in emergencies, the applicant will notify the
regional director and resident engineer in writing, at least 72 hours before work is started. This notice will contain a
complete description of the work to be done, including sketches where essential. (2) In emergencies, telephone notice
will be immediately given the resident engineer, and the full requirements of paragraph (1) above will be met as soon as
possible, and not later than the first working day following the emergency notice.
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 P-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 be 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.
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.”
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11. COST OF INSPECTION AND SUPERVISION: Prior to issuance of this 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 workdays involved.
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 Highway
Design Manual Appendix 5A.
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
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 applicable to the Highway Work Permit.
B. USE AND OCCUPANCY FOR FIBER OPTIC FACILITIES AND SUPPORTING INFRASTRUCTURE
15. USE AND OCCUPANCY: This permit also licenses the Permittee to temporarily use and occupy the state highway
right-of way specifically described herein subject to the covenants, terms and conditions provided below.
16. This permit supersedes the permit number
issued to
in the amount of
per
approved by the Director, Office of Right of Way on
(select)
.
17. Property description and use: [[Description]] as depicted on the application its attachments and sketch(es) attached
hereto and made a part hereof (Fiber Optic Facility). The property covered by this permit shall be used only for the use
described herein and for no other purpose whatsoever.
18. The Use & Occupancy permit shall be renewed automatically for successive terms of one month each unless canceled
by either party. Cancellation by the State requires thirty (30) days written notice, except for cause, in which event
cancellation can be effective on ten (10) days written notice. Permittee may cancel this permit by giving thirty (30) days
written notice.
19. The fee to be charged shall be: $
per month, payable annually in advance in the amount of $
per year
beginning
20. Payment of the annual fee for the Use & Occupancy Permit is due on the first of the month unless otherwise stated.
Fee must be paid by check, bank cashier's check or money order payable to "Department of Transportation" and mailed or
delivered to:
New York State Department of Transportation
Revenue Unit, POD 5-2
50 Wolf Road
Albany, New York 12232
21. The parties acknowledge that this instrument is not a lease but is merely a permit to occupy and use, and therefore a
landlord tenant relationship is not hereby created; and further, that since this is not a lease, Section 5 321 of the General
Obligations Law does not apply to this permit to the extent permitted by law.
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