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INSTRUCTIONS FOR COMPLETING THE CONSOLIDATED APPLICATION

This is a fillable form application, which can be signed and submitted electronically with 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

Once the Use & Occupancy Permit is executed, and upon satisfaction of all requirements and receipt of the Highway Work Permit fee, the Regional Permit Engineer may issue the Highway Work Permit to allow construction to commence.

APPLICATION PAGE 11

• 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 andphone number(s) of emergency contact person. Note that the Permittee for the Use and Occupancy Permit may bedifferent 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.

Form PERM 75

Consolidated Application and Permit for Highway Work and Use & Occupancy For Fiber Optic Facilities and Supporting Infrastructure

Effective May 1, 2020

A USE & OCCUPANCY PERMIT MUST BE EXECUTED BEFORE A HIGHWAY WORK PERMIT CAN BE ISSUED FOR CONSTRUCTION

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• Plans and specifications must 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. (on Page 12)

BACK OF APPLICATION PAGE 13

• 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 cablesegments 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 opticinstallation is later found to be outside of the state highway right of way, the State will not reimburse permit feespaid.

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

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 useby Permittee only for the purpose stated in this Permit and only on the date(s) and for the duration designated in thispermit. This Permit does not authorize any infringement of federal, state or local laws or regulations, is limited to theextent of the authority of NYSDOT and is transferable and assignable only with the written consent of the Commissionerof Transportation. The Commissioner reserves the right to modify fees and to revoke or annul the Permit at any time, athis/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 beendesigned, constructed, or maintained for the purpose of the conduct of the work. The Permittee assumes fullresponsibility for planning and conducting a safe and orderly project that does not expose workers or the public to anyunreasonable 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 conductingthe work. The Permittee assumes all responsibility for assuring that the use of the highway/property conforms toapplicable 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 workbeing 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 NewYork State Department of Transportation named as an additional insured on the commercial general liabilitypolicy. An industry standard ACORD 25 form with an ACORD 855 Addendum is acceptable evidence of therequired coverage. Certificate Holder should be indicated as New York State Department of Transportation, withthe address of the issuing office.

• A fully executed Undertaking Agreement may be provided by Municipalities, Public Utilities, TransportationCorporations, Public Service Corporations or Railroads, as an alternative to providing proof of commercial generalliability 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 compensationinsurance and disability coverage as noted in the provisions of the Worker's Compensation Law and Acts amendatorythereof 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 ofexemption from this requirement (Form CE-200).

5. INDEMNIFICATION: Permittee agrees that, in addition to any protection afforded to NYSDOT under any availableinsurance, NYSDOT shall not be liable for any damage or injury to the Permittee, its agents, employees, or to any otherperson, or to any property, occurring on the site or in any way associated with Permittee’s activities or operations; whetherundertaken by Permittee’s own forces or by contractor or other agents working on Permittee’s behalf. To the fullest extentpermitted by law, the Permittee agrees to defend, indemnify and hold harmless the State of New York, NYSDOT and theiragents 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:

• Notification to the applicable NYSDOT residency, 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).• At conclusion of work, return Page 3 of the Highway Work Permit to Resident Engineer to begin closeout.

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 amountdesignated by the Department of Transportation, may be required before a permit is issued, in order to guaranteerestoration of the site to its original condition. A fully executed Undertaking Agreement may be accepted as an alternativesecurity, where applicable. If the Department is obliged to restore the site to its original condition, the costs to theDepartment will be deducted from the amount of the Permittee's deposit at the conclusion of the work. Costs in excess ofthe bond/deposit on file will be billed directly to the Permittee. If P-permittee posts a Letter of Credit, the Department mayelect 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 ANSIClass 2 requirements.

• No unnecessary obstruction is to be left on the pavement or the state highway right-of-way, or in such a position asto 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 theRegional Maintenance Engineer.

8. COSTS INCURRED BY ISSUANCE OF THIS PERMIT: All costs beyond the limits of any liability insurance, suretydeposits, etc. are the responsibility of the Permittee. The State shall be held free of any costs incurred by the issuance ofthis permit, direct or indirect.

9. SUBMITTING WORK PLANS: All initial plans should be submitted in pdf format (1” = 50’). Plans should be completeand sufficiently detailed as required for construction. Prior to permit approval, applicant must submit three (3) sets of paperplans, or as directed by regional reviewer. For underground installations, plans must show location of existing undergroundutilities. All installations shall be in compliance with NYCRR 17 Part 131 Accommodation of Utilities Within State Rightof Way, and the NYSDOT “Blue Book”, titled Requirements for the Design and Construction of Underground UtilityInstallations within State Highway Right-of-Way. Temporary traffic control plans shall be in compliance with theNational Manual of Uniform Traffic Control Devices (MUTCD) and the New York State Supplement.

Plans shall include (but not be limited to) such details as: 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. All temporary traffic control plans must indicate lane and shoulder widths. A description of the proposed method of construction will be included. Be sure to 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 their work with any State construction being conducted.

10. TRAFFIC MAINTENANCE: A plan detailing how the Permittee intends to maintain and protect traffic shall be submittedwith work plans. Traffic shall be maintained on the highway in a safe manner during working and non-working hours untilconstruction is completed. The Permittee is responsible for traffic protection and maintenance, including adequate use ofsigns, barriers, and flag persons during working and non-working hours until construction is completed. All sketches will bestamped with "MAINTENANCE OF TRAFFIC SHALL BE IN CONFORMANCE WITH THE NATIONAL MANUAL ONUNIFORM 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 signan INSPECTION PAYMENT AGREEMENT FOR HIGHWAY WORK PERMITS (FORM PERM 50) agreeing to the paymentof 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 Departmentof Transportation has jurisdiction. (Local governments issue permits for highways under their jurisdiction.) Worklocations must be approved by the Department.

• Maintenance: Unless noted otherwise, applicant shall be fully responsible for the maintenance of all items installedand/or altered as shown on the approved permit plans and documents.

• Work Commencement: The Permittee shall have a copy of the permit available at the site during the constructionperiod. 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 permitwork 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 thepermit, the person and his or its successors in interest shall be responsible for the maintenance and repair of such work orportion 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.

Issued to

approved by the Director, Office of Right of Way on

16. This permit supersedes the permit number

in the amount of $ per.

17. Property description and use: as described on Page 11 below and as depicted on the application its attachments andsketch(es) attached hereto and made a part hereof (Fiber Optic Facility). The property covered by this permit shall be usedonly 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 canceledby either party. Cancellation by the State requires thirty (30) days written notice, except for cause, in which eventcancellation can be effective on ten (10) days written notice. Permittee may cancel this permit by giving thirty (30) dayswritten 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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22. The Permittee understands and agrees that if the full amount of the fee as stated herein is not paid within thirty daysfrom the date billed as indicated on the billing invoice, interest penalties and collection fees will be imposed under theprovisions of Section 18 of State Finance Law.

23. The Permittee understands and agrees that the fee charged by the State may periodically be updated to reflect fairmarket value and the Permittee will enter into a new permit for the new fee if the Permittee wishes to remain in occupancy.Failure to execute a new permit will require Permittee to immediately vacate the premises.

24. (reserved)

25. Permittee shall be responsible for identifying the State right-of-way within which the Permittee’s Fiber Optic Facility willbe placed. If placement of the Fiber Optic Facility is found to be outside of the State right-of-way, the issuance of the Useand Occupancy Permit does not create the presumption of validity of the use or occupancy and does not constituteapproval from the State.

26. Permittee, at the Permittee's expense shall maintain General Liability Insurance coverage provided in accordance withPERM 75 Submission Package Requirements, for the term of the Use and Occupancy Permit, issued by an insurancecarrier licensed to do business in the State of New York for the protection of the State of New York and Permittee againstany claims, suits, demands or judgments by reason of bodily injury, including death, and for any claims resulting in propertydamage occurring on or in proximity to the permit area.

Such General Liability Insurance shall be in the amount no less than $2,000,000 (combined property damage and/or bodily injury, including death) single limit per occurrence, and shall name the People of the State of New York as an additional insured.

The Permittee will furnish the State with a certificate of insurance, with a thirty (30) day’s prior written notice of any cancellation or major change in the policy conditions. The permit shall be voided if insurance is cancelled, modified or lapses.

Approval of this permit shall be contingent upon receipt, by the State, of a copy of a properly executed insurance certificate.

27. Permittee shall not place or store, or allow others to place or store, any flammable, explosive, hazardous, toxic orcorrosive materials, debris of any description, garbage or any materials commonly referred to as "junk" within the permitarea, except fuel kept in the fuel tanks of legally parked vehicles allowed under the terms of this permit. Failure to complywith this provision may result in a ten (10) day’s written notice of cancellation of the permit in accordance with the terms ofthis permit. The Permittee is responsible for the removal of these materials and/or all expenses incurred in their removal.

28. All arrangements of services for utilities, removal of garbage, rubbish, litter, snow and ice will be made by thePermittee at the Permittee's expense, unless hereafter specified. The State shall have no responsibility to provide anyservices not specifically set forth in writing herein. Permittee shall comply with all local and State building standards/codesin the installation or repair of any utilities including but not limited to electricity and plumbing. Permittee is responsible forkeeping and maintaining the premises in a safe and clean condition, for the regular and prompt removal of garbage,rubbish, litter, snow and ice. Permittee shall be responsible for preventing damages to the plumbing system and premisescaused by lack of heat or water damage from leaks.

29. Permittee is responsible for any repairs, improvements or maintenance work of any kind on the property at Permittee'sexpense. The State may, at any time, periodically inspect the premises to determine whether same is in good repair andmaintenance, structurally sound, and that no unsafe, hazardous, unsanitary, or defective conditions exist.

30. Permittee hereby agrees to admit State representatives and prospective purchasers or permittees to examine thesepremises during reasonable business hours.

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31. Permittee is responsible to maintain the occupancy in compliance with any and all applicable local, State, and Federallaws, ordinances, codes, rules and regulations affecting the use of the property. Permittee shall not conduct or allow anyuse or activity on the premises inconsistent with law and shall not conduct or allow any use or activity on the premiseswhich may require a permit or other approval by a government agency without having lawfully obtained such permit orapproval.

32. The State shall have no responsibility whatever for the loss or destruction of any improvements made by the Permitteeor for personal property stored or being used on the premises.

33. Permittee shall not assign or transfer the permit to any other parties in part or in whole without the prior writtenconsent of the State. Failure to comply with this provision may result in ten (10) day’s written notice of cancellation of thepermit by the State, and the State may immediately take possession and terminate all rights of the Permittee as of suchmoment.

34. It is understood and agreed by and between the parties that the Permittee will not be entitled to any relocation benefitsprovided under State and Federal law.

35. Permittee agrees and understands that the State is under no obligation to sell the property to the Permittee and thatno commitment, express or implied, is made by the State to give the Permittee any preemptive right of purchase.

36. Upon cancellation of the permit by either party, the permit area must be either, at the option of the State, restored toits original condition and should the Permittee fail to restore the site, the Permittee shall reimburse the State for any andall costs incurred by the State for the restoration of the permit area or the fiber optic facilities left in place and abandonedto the State with the State taking possession thereof. Upon such abandonment permittee waives all claims and rights tothe installed fiber, any improvements, and any costs associated with such installation or improvements. This provisionmay not be waived or modified except with prior written consent from the State.

37. The Permittee shall not place advertising or sponsorship signs in the permit area without the express written consentof the New York State Department of Transportation.

38. In accordance with Article 15 of the Executive Law (also known as the Human Rights Law) and all other State andFederal statutory and constitutional non discrimination provisions, the Permittee will not discriminate against anyemployee or applicant for employment because of age, race, creed, color, national origin, sexual orientation, militarystatus, sex, disability, predisposing genetic characteristics, or marital status. Neither shall the Permittee discriminate inthe use of the premises nor any access thereto if such premises are used as a public accommodation or in connectionwith a public service.

39. The Permittee for his/her self, and/or the Permittee’s personal representatives, successors in interest, and assigns, asa part of the consideration hereof, does hereby covenant and agree, that in the event improvements are made over orunder such land and the furnishing of services thereon and/or facilities are constructed, maintained, or otherwise operatedon the said property described in Item 1 of this permit for a purpose for which a New York State Transportation program oractivity is extended or for another purpose involving the provision of similar services or benefits, the Permittee shallconstruct such improvements and maintain and operate such facilities and services such that (1) no person on thegrounds of race, color, or national origin, sex, age, and disability/handicap, shall be excluded from participation in, deniedthe benefits of, or be otherwise subjected to discrimination in the use of said facilities, (2) that in the construction of anyimprovements on, over or under such land and the furnishing of services thereon, no person on the grounds of race, color,or national origin, sex, age, and disability/handicap, shall be excluded from participation in, denied the benefits or, orotherwise be subjected to discrimination, (3) that the Permittee shall use the premises in compliance with all otherrequirements imposed by or pursuant to title 49, Code of Federal Regulations, Part 21, Nondiscrimination in Federally-assisted programs of the Department of Transportation – Effectuation of Title VI of the Civil Rights Act of 1964; and toTitle 23 Code of Federal Regulations, Part 200, Title VI Program and Related Statutes – Implementation and ReviewProcedures; and further as said Regulations may be amended.

That in the event of breach of any of the above nondiscrimination covenants, the State shall have the right to terminate the permit and to re-enter and repossess said land and the facilities thereon and hold the same as if said permit had never been made or issued.

40. If any of the provisions of this permit are held invalid, such invalidity shall not affect or impair other provisions hereinwhich can be given effect without the invalid provisions, and to this end the provisions of this permit are severable.

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41. Additional provisions to permit:

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42. Liability Insurance Requirements: (For more information, go to www.dot.ny.gov/permits-insurance)

In most cases, Permittee must provide proof of Commercial General Liability insurance coverage with limits of liability not less than $2,000,000 per claim/occurrence, unless any of the following circumstances exist, in which case the limits of liability shall not be less than $5,000,000 per claim/occurrence:

• The estimated value of permitted work in state right-of-way is $250,000 or more, or• The permitted work requires or includes the construction, alteration or maintenance of underground features at

any depth five feet or more below grade, OR the construction, alteration or maintenance of overhead features thatinclude, but are not limited to, traffic signals, overhead sign structures, or other grade separation structures.

ACORD 25 with ACORD 855 (New York Construction Addendum) shall be submitted as an acceptable proof of liability coverage. New York State Department of Transportation should be named as Additional Insured and as the Certificate Holder at the address of the regional issuing office, with a thirty (30) day prior written notice of any cancellation or major change in the policy conditions.

Such Commercial General Liability Insurance shall be combined property damage and/or bodily injury, including death single limit per occurrence. The permit shall be voided if insurance is cancelled, modified or lapses. Approval of this permit shall be contingent upon receipt, by the State, of a copy of a properly executed insurance certificate.

Municipalities, public utilities, public authorities and railroads may elect to provide a fully executed Undertaking Agreement as a substitute for providing proof of insurance coverage, or any other financial security otherwise required.

When the estimated cost of work being performed in the right-of-way equals or exceeds $250,000, Permittee must additionally provide proof of a Protective Liability (OCP) insurance policy with a minimum liability limit of $1,000,000 per occurrence, with New York State Department of Transportation as Named Insured.

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 coverage automatically terminates the permit.

PERM 75 Submission Checklist

Submission package must include the entire PERM 75 application, with all work plans and supporting

documents, including the following:

TECHNICAL REVIEW

Work Plans: At initial submission, all plans should be in pdf format (1” = 50’). Plans

should be complete and sufficiently detailed as required for construction.

Prior to permit approval, applicant must submit three (3) sets of paper plans, or as

directed by regional reviewer.

For underground installations, plans must show location of existing underground utilities.

All installations shall be in compliance with NYCRR 17 Part 131 Accommodation of

Utilities Within State Right of Way, and the NYSDOT “Blue Book”, titled Requirements for

the Design and Construction of Underground Utility Installations within State Highway

Right-of-Way.

All temporary traffic control plans must indicate lane and shoulder widths. Temporary

traffic control plans shall be in compliance with the National Manual of Uniform Traffic

Control Devices (MUTCD) and the New York State Supplement.

Applicant must submit form PERM 50 Inspection/Supervision Payment Agreement

If consultant inspection is required, Applicant must submit form PERM 36 Attachment to

Highway Work Permit - Consultant Inspection Agreement

Use and Occupancy Fiber Optic Installation Segment Chart (See chart on Page 14)

Aerial Depiction of Fiber Installation (See Page 2 for additional information)

FINANCIAL REVIEW

ACORD 25 Certificate of Liability Insurance, with NYSDOT as Additional Insured.

Certificate Holder shall be the NYSDOT with the address of the regional office issuing

the permit. Minimum liability coverage limit should be no less than $2million/$5 million

per occurrence (See Liability Insurance Requirements on Page 9 for details).ACORD 855 New York Construction Certificate of Liability Insurance Addendum. Line D

should list the appropriate Additional Insured endorsement forms. If requested,

Applicant shall submit a copy of the Additional Insured endorsements.

Performance Security – PERM 44 Surety Bond (Cash Guarantee or Letter of Credit as

alternatives)

Proof of Workers’ Compensation Insurance (Form C-105.2, U-26.3, SI-12) or proof of

exemption

Proof of Disability Benefits Coverage (Form DB-120.1, DB-155), or proof of exemption

PAYMENTS

Highway Work Permit Fee (See Page 13 for chart of work types and calculation of fee)

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PERM 75 (May 2020)

STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION Consolidated Application and Permit for Highway Work and Use & Occupancy

For Fiber Optic Facilities and Supporting Infrastructure

Application is hereby made for a Highway Work Permit and Use and Occupancy Agreement for fiber optic facilities and supporting infrastructure:

Liability Insurance (check one): _______ General Liability Insurance ______ Undertaking (Utilities, Municipalities, Railroads)

APPLICANT FOR HIGHWAY WORK PERMIT:

Name _______________________________________________

Address _____________________________________________

City ______________________ State ________ Zip __________

Applicant Phone (_____)_________________________________

Applicant Email Address ________________________________

Emergency Contact ____________________________________

Emergency Phone (_______) ____________________________

RETURN HIGHWAY WORK PERMIT TO: (if different)

Name _________________________________________________

Address _______________________________________________

City ______________________ State ________ Zip ____________

APPLICANT FOR U&O PERMIT: (OWNER OF FIBER FACILITY)

Name _______________________________________________

Address _____________________________________________

City ______________________ State ________ Zip __________

Tax ID# ______________________________________________

Applicant Phone (_____)_________________________________

Applicant Email Address ________________________________

PLEASE LIST ANY ADDITIONAL PERMIT APPLICANTS ON AN ATTACHED PAGE, AND PROVIDE THE SAME INFORMATION

RETURN DEPOSIT/BOND TO: (if different)

Name _______________________________________________

Address _____________________________________________

City ______________________ State ________ Zip __________

DESCRIPTION OF PROPOSED WORK:

WILL OVERHEAD OR UNDERGROUND (5’+) OPERATIONS BE INVOLVED IN THE PROPOSED WORK?

Estimated cost of work being performed in highway right-of-way: $

Anticipated duration of work: From __________________ to __________________ (applies to the operations indicated)

LOCATION: State Route: _________ Located Between Reference Markers ____________________ and ____________________

City/Town/Village of _____________________________ County of ________________________________

UTILITY REFERENCE/WORK ORDER NUMBER:

NOTE: PERMIT IS ISSUED CONTINGENT UPON ALL LOCAL REQUIREMENTS BEING SATISFIED

ACKNOWLEDGMENT: ON BEHALF OF THE APPLICANT, I HEREBY REQUEST A HIGHWAY WORK AND USE AND OCCUPANCY PERMIT AND DO ACKNOWLEDGE AND AGREE TO THE RESPONSIBILITIES OF PERMITTEE AND THE OTHER OBLIGATIONS SET FORTH IN THIS PERMIT AND WARRANT COMPLIANCE THEREWITH. IN CONSIDERATION OF THE GRANTING OF THE PERMIT, THE UNDERSIGNED ACCEPTS ALL OF THE ABOVE TERMS, CONDITIONS AND PROVISIONS.

Applicant 1 Name and Title

Applicant 1 Signature Date

☐ I am the Applicant noted directly above and it is my intent, to sign this record/document by electronically submitting this record/document 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 record/document and thisaffirmation. I understand and agree that by electronically signing and submitting this record/document in this fashion I am affirming to thetruth of the information contained therein.

Applicant 2 Name and Title

Applicant 2 Signature Date

☐ I am the Applicant noted directly above and it is my intent, to sign this record/document by electronically submitting this record/document 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 record/document and thisaffirmation. I understand and agree that by electronically signing and submitting this record/document in this fashion I am affirming to thetruth of the information contained therein.

___________________________________________________________________________________________________________________________

FOR NYSDOT USE

USE AND OCCUPANCY PERMIT

RECOMMENDED by Regional Real Estate Officer

Region

ACCEPTED and APPROVED Commissioner of Transportation for the People of the State of New York

by Director, Office of RIght of Way

RECOMMENDED by Regional Real Estate Officer

DateDate

DateDate

PPeerrmmiitt NN: uummbbeerr: J

HIGHWAY WORK PERMIT

RECOMMENDED by Resident Engineer

Residency Date

ACCEPTED and APPROVED Commissioner of Transportation for the People of the State of New York

by Regional Traffic Engineer

Region Date

Permit Number:

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Letter of Credit

UTILITY CHARGE ACCOUNT NUMBER:

PERFORMANCE SECURITY (Select One): Guarantee Deposit – Cash Performance Bond

Guarantee Deposit Amount: Guarantee Deposit Check Number of Bond Number:

Operational Type and Description HIGHWAY WORK PERMIT FEES

Base Fee QTY Unit Rate Sub Total Total Fees

ORIGINAL INSTALLATION Number of feet/poles

1a1 Underground - excavation, tunneling, boring, installing, etc. 32 .32/foot

1a2 Underground - Commercial subsurface connection 32 .32/foot

1a3 Underground - Residential subsurface connection 32 .32/foot

1b1 Overhead - Erecting poles, towers 63 2.50/unit

1b2 Overhead - Running new lines 63 1b3 Overhead - Commercial service connection 19 1b4 Overhead - Residential service connection 19 1c1 Installation on bridge or culvert 63

1c2 Installation on bridge or culvert requiring structural changes 625

MAINTENANCE Number of regions/counties 2a Maintenance, single job 32

2b1 Annual maintenance per region 2500 2b2 Annual maintenance per county 625 2c Repair of water or sewer lines 32 2d DOT requested maintenance N/C

AFTER ORIGINAL CONSTRUCTION Number of regions/counties

3a1 Annual – includes overhead connections – per region 2500

3a2 Annual – includes overhead connections – per county 625

3b DOT requested relocation N/C 3c Commercial subsurface service connection 32 3d Commercial overhead service connection 19 3e Residential subsurface service connection 32 3f Residential overhead service connection 19

MISCELLANEOUS UTILITY WORK 4 Miscellaneous (describe below) 32

(To be completed by NYSDOT issuing office)

Project Identification Number ______________________________

State Highway (SH) Number _______________________________ Record ID Number _____________________________

Fiber

Optic

Segment

Municipality Highway

Number

Beginning

ReferenceMarker

Ending

ReferenceMarker

Longitudinal

or

Transverse

Aerial or

Under-

ground

Number

of Cables

Number of

Strands per

Cable

Segment Length

(Linear Feet)

Additional Capacity in Conduits-

including Microducts (# of cables)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20