Form Ta W41337 – Fill Out and Use This PDF

TA-W41337 (07/2014)	New York State Thruway Authority
Page 1 of 3	OCCUPANCY PERMIT APPLICATION

Section I	Applicant Identification Information
(Check one)	Individual	Municipality	Utility	New	Amended
	Business/Corporation	Public Agency	Not for Profit
Name				Federal ID No.

Section II Facility Identification Information

LOCATION OF FACILITY (check all that apply)

MILEPOST BOUNDARY (if known)

IF APPLICABLE, CHECK ONE

Underground

Aerial

Beginning Milepost No.

Master agreement/permit

Depth in inches

Bridge

Surface

If longitudinal, include

Attachment

Orientation (Check one or both)

ending Milepost No.

Co-locate agreement

Longitudinal

Direction of travel (N/S/E/W)

Transverse - Offset from bridge or cross street

GPS Coordinates (if known)

Utility agreement

feet

TYPE AND SIZE OF FACILITY (check one and enter size if known)

Water Mains

Telephone

Fiber Optic

Drainage

Gas Mains

Cable Television

Parking

Building Structure

Sewers

Electric

voltage

Storage

Communications Tower

Communications Tower/Co-Locate

Other (please describe)

PURPOSE OF PERMIT (please provide brief description and location)

Section III

SEQRA

Section IV

Insurance - Complete if known

Has a SEQRA determination been made?

Type of insurance furnished:

Yes

No

Don't know

ACORD 25 Certificate of Liability Insurance & Supplemental Insurance Certificate (TA-W51343-9)

If yes, please provide supporting

Undertaking Effective Date

information (by whom, when, etc.)

Duplicate Policy No.

Effective Date

Performance Bond

Other

Section V Read Thoroughly Before Signing - Applicant Affirmation/Certification

Application is hereby made by the undersigned for issuance of a permit. I understand and agree that permits are revocable unilaterally by the Thruway Authority (Authority). Therefore, I understand and agree that if granted a permit: I will maintain all installations so permitted subject to the risk of having to relocate or remove such installations at my sole expense, in accordance with the directions of the Authority; I am responsible to reimburse the Authority for any surveys, appraisals and/or any other necessary expenses incurred by the Authority as a result of such permit; and I am solely responsible for obtaining any other consents or permits that may be necessary to accomplish the purposes of such permit.

I further understand that this Application incorporates by reference the terms and conditions of the NEW YORK STATE THRUWAY AUTHORITY OCCUPANCY AND WORK PERMIT ACCOMMODATION GUIDELINES (TAP-401), the UTILITY OCCUPANCY SUPPLEMENT (TAP-401U), the FIBER OPTIC FACILITIES SUPPLEMENT (TAP-401F) and the DESIGN AND CONSTRUCTION REQUIREMENTS FOR OCCUPANCIES (TAP-421A-E), as such documents may be amended. I agree that if granted a permit, this Application becomes a part of such permit, and as a condition of the issuance of the permit and/or exercise of any privileges granted thereunder, I shall comply with all terms and conditions of this Application, any condition rider placed on such permit and the RULES AND REGULATIONS OF THE NEW YORK STATE THRUWAY AUTHORITY, as same may be amended.

I affirm and certify that all information provided to the Authority, whether written or verbal, including, but not limited to, this Application and accompanying Forms and Supporting Documents, is complete, true and accurate.

Dated this		day of		, 20		.
								Print Name of Applicant
			Signature					Title (if applicable)

Section VI	Submit Application to the Appropriate Thruway Authority Division Permit Coordinator
DIVISION		HIGHWAY SECTIONS		DIVISION MILEPOST LIMITS
New York		New York (Mainline)		0.00 - 76.50
		• Garden State Parkway Connection		GS 0.00 - GS 2.40
		• New England Section		NE 0.17 - NE 15.01
		• I-287 Cross Westchester*		CWE 0.00 - CWE 10.90
Albany		Albany (Mainline)		76.50 - 197.90
		• Berkshire Section		B 0.00 - B 24.28
Syracuse		Syracuse (Mainline)		197.90 - 350.60
Buffalo		Buffalo (Mainline)		350.60 - 496.00
		• Niagara Section		N 0.00 - N 21.50
		ADDRESSES AND PHONE NUMBERS
NYS Thruway Authority		NYS Thruway Authority	NYS Thruway Authority	NYS Thruway Authority
New York Division		Albany Division	Syracuse Division	Buffalo Division
Division Permit Coordinator		Division Permit Coordinator	Division Permit Coordinator	Division Permit Coordinator
4 Executive Blvd.		P.O. Box 861	290 Elwood Davis Rd, Suite 250	455 Cayuga Rd, Suite 800
Suffern, NY	10901	Albany, NY 12201-0861	Liverpool, NY 13088-2118	Cheektowaga, NY 14225
Phone: (845) 918-2510		Phone: (518) 436-2710	Phone: (315) 438-2420	Phone: (716) 635-6253
Fax: (845) 918-2596		Fax: (518) 436-0233	Fax: (315) 461-0765	Fax: (716) 626-5362

Overnight mail address: 270 Mt. Hope Drive Albany, NY 12209

*For the Cross Westchester Expressway (I-287), Occupancy Permits are issued by the New York State Department of Transportation and Work Permits are issued by the New York State Thruway Authority.

Please review the THRUWAY AUTHORITY OCCUPANCY AND WORK PERMIT ACCOMMODATION GUIDELINES (TAP-401) which is available on the Authority's web page or by request prior to submitting your application.

In order for the Authority to formally consider your application, the forms listed below must be completed and submitted as part of the application.

FORMS THAT MUST BE COMPLETED AND SUBMITTED: (available from Division Permit Coordinator or from the Authority's website at www.nysthruway.gov)

TA-W41337 Occupancy Permit Application - Pages 1 - 3

(Original form ONLY will be accepted; read and complete the applicant sections listed on the permit)

TA-W51343-9 Supplemental Insurance Certificate (Original form ONLY will be accepted)

ACORD 25 Certificate of Liability Insurance

(Available from your insurance agent; original form ONLY will be accepted)

SUPPORTING DOCUMENTS:

Supporting documents, as listed below, may be required. The Permit Coordinator for the Division in which you are applying for occupancy should be contacted to determine what additional supporting documents will be required.

Site/Operation Plan (3 copies)

Must be stamped by a New York State Licensed Professional Engineer or Registered Architect

•Plan and profile drawn to scale

•Highway ROW, C/L and stationing

•Edge of pavement and shoulders

Property Survey stamped by a New York State Licensed Land Surveyor (3 copies)

Utility Pole/Conduit Authorization/Letter of Agreement (for non-owner)

Drainage Analysis/Storm Water Management Report

Other

FEES:

Application Fee:	$750 (minimum, non-refundable)
Amendment Fee: Nominal (name/address change)		$	25
(per permit)	Moderate (routine engineering/administrative review)	$	250
	Comprehensive (extensive engineering/administrative review)	$	500
Annual Fee:	The Authority reserves the right to charge annual fees in accordance with the Authority's Fee Policy for
	Occupancy and Work Permits. Contact the Division Permit Coordinator for details.

MAKE CHECKS PAYABLE TO:

"NEW YORK STATE THRUWAY AUTHORITY"

Please be sure to include all required forms and any required supporting documents.

These items must accompany this Application for processing.

Submit forms, fees and information to appropriate Division Permit Coordinator address listed in Section VI.