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Work Permit Application

2. 1. Reason For Filing

   1. Initial Permit (Complete all sections)
   2. Renewal Permit without changes
   3. Renewal Permit with Changes (Complete all sections)

   Required for all applications.
3. When was the last time you performed work on the island?
   -- Select One --First TimeWithin the last yearOver a year ago
5. Requested Daily Hours of Work
   Requested Daily Hours of Work Start Time

   —

   Requested Daily Hours of Work End Time
6. Expected work start date:*
   Expected work start date:
   Work date MUST be at least 10 business days from today.
7. Expected work end date:
   Expected work end date:
11. 2. Location Information
    Required for <b>all</b> applications.

    Required for all applications.
13. Building/Location Name:*
14. Street Address*
16. Property Manager:
20. 3. Detailed Job Description / Scope of Work*
    Please thoroughly describe the project. Please include potential impacts to the surrounding area/community- will sidewalks be closed? Will businesses be able to function around this work?
22. Is the requested work limited by temperature/weather? If yes, please describe:*
24. Number and type of vehicles that will be present for the planned work:*
26. Do you require on-street parking to be reserved for work vehicles? If so, how many spaces?
28. Is a temporary road closure required? If so, please describe:
29. Will you have flagmen/traffic control?

    1. Yes
    2. No
33. 4. Applicant
    Required for <b>all</b> applications.

    Required for all applications.
35. 1. Owner
    2. Contractor
37. Last Name*
38. First Name*
40. Business Name
41. Business Telephone
43. Business Address
44. Business Fax
46. City
47. State
48. Zip
50. Mobile Telephone*
51. Email*
52. Taxpayer ID
56. 5. Sub‐Contractors
    Required for <b>all</b> applications.

    Required for all applications.
58. 1. Yes
    2. No
59. Attach separate sheet if there are more than one.
61. Last Name
62. First Name
63. Middle Initial
65. Business Name
66. Business Telephone
68. Business Address
69. Business Fax
71. City
72. State
73. Zip
74. Mobile Telephone
76. E‐Mail
77. Taxpayer ID
81. 6. Insurance
83. Certificate of Insurance
85. RIOC Insurance Requirements
    The Contractor shall insure and shall require each of its subcontractors to carry the following insurance:<br>Commercial General Liability Insurance providing both bodily injury including death and property damage insurance in a limit of not less than two million dollars ($2,000,000.00) combined single limit basis. Such insurance is to be written on an occurrence basis <br>Automobile Liability and Property Damage Insurance in an amount not less than five hundred thousand dollars ($500,000.00) combined single limit for both bodily injury and property damage; <br><br> Contractor shall provide Worker’s Compensation Insurance and Employer’s General Liability Insurance as required under the Worker’s Compensation Law.<br><br> Certificates of Insurance for all aforementioned coverage’s shall be provided to RIOC prior to the commencement of Work and bear notations evidencing a minimum of 10 day cancellation notice to RIOC. Such insurance policies shall name RIOC, the Empire State Development Corporation, the Division of Housing and Community Renewal, the State of New York and the City of New York as additional insureds. <br><br> Certificates all addressed care of:<br> c/o: Director of Engineering, Roosevelt Island Operating Corporation, 591 Main Street, Roosevelt Island, New York 10044 <br>RIOC will keep certificates on file for the other New York State and New York City Agencies.

    The Contractor shall insure and shall require each of its subcontractors to carry the following insurance:
    Commercial General Liability Insurance providing both bodily injury including death and property damage insurance in a limit of not less than two million dollars ($2,000,000.00) combined single limit basis. Such insurance is to be written on an occurrence basis
    Automobile Liability and Property Damage Insurance in an amount not less than five hundred thousand dollars ($500,000.00) combined single limit for both bodily injury and property damage;
    
    Contractor shall provide Worker’s Compensation Insurance and Employer’s General Liability Insurance as required under the Worker’s Compensation Law.
    
    Certificates of Insurance for all aforementioned coverage’s shall be provided to RIOC prior to the commencement of Work and bear notations evidencing a minimum of 10 day cancellation notice to RIOC. Such insurance policies shall name RIOC, the Empire State Development Corporation, the Division of Housing and Community Renewal, the State of New York and the City of New York as additional insureds.
    
    Certificates all addressed care of:
    c/o: Director of Engineering, Roosevelt Island Operating Corporation, 591 Main Street, Roosevelt Island, New York 10044
    RIOC will keep certificates on file for the other New York State and New York City Agencies.
89. 7. Maps/Drawings/Safety Plan
    Please include a map and safety plan of the proposed work area.

    Please include a map and safety plan of the proposed work area.
91. Document A
93. Document B
95. Document C
99. 8. Applicant Statement and Signature
    Required for <b>all</b> applications.

    Required for all applications.
101. I, hereby state the information is correct and complete to the best of my knowledge. I hereby assume responsibility for all statements applying to the applicant and all documents submitted along with this application. I understand falsification of any statement is punishable by a fine or imprisonment, or both. I also understand it is unlawful to give to a state employee, or for a state employee to accept, any benefit, monetary or otherwise, either as a gratuity for properly performing the job or in exchange for special consideration. Such action is punishable by imprisonment or fine or both.

     I, hereby state the information is correct and complete to the best of my knowledge. I hereby assume responsibility for all statements applying to the applicant and all documents submitted along with this application. I understand falsification of any statement is punishable by a fine or imprisonment, or both. I also understand it is unlawful to give to a state employee, or for a state employee to accept, any benefit, monetary or otherwise, either as a gratuity for properly performing the job or in exchange for special consideration. Such action is punishable by imprisonment or fine or both.
103. Name*
105. Date*
     Date
107. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
109. Electronic Signature*
Leave This Blank:


113. 1. Receive an email copy of this form.
114. Email address

     This field is not part of the form submission.

115. Submit

* indicates a required field