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Work Permit Application

  1. 1. Reason For Filing

    Required for all applications.

  2. Work date MUST be at least 10 business days from today.

  3. 2. Location Information

    Required for all applications.

  4. 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?

  5. Will you have flagmen/traffic control?

  6. 4. Applicant

    Required for all applications.

  7. 5. Sub‐Contractors

    Required for all applications.

  8. Attach separate sheet if there are more than one.

  9. 6. Insurance

  10. RIOC Insurance Requirements

    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.

  11. 7. Maps/Drawings/Safety Plan

    Please include a map and safety plan of the proposed work area.

  12. 8. Applicant Statement and Signature

    Required for all applications.

  13. 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.

  14. 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.

  15. Leave This Blank:

  16. This field is not part of the form submission.