information package for permit traffic signals...information package for permit traffic signals...

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INFORMATION PACKAGE FOR PERMIT TRAFFIC SIGNALS

(April 21, 2014)

The following package includes the basic forms needed to initiate the Permit Traffic Signal

process.

The following is a list of the contents of this package

___ Signal Permit Process

___ Regional & MO Permit Contacts

___ Application Filing Instructions (Form SM-00001 is used as an example)

___ Form SM-00001: Application and Permit to Install and Operate A Traffic Control Signal

On State-Owned Property.

___Certificate of Liability Insurance Form (referred to in the application)

___Certificate of NYS Workers Compensation and Disability Insurance (referred to in the

application)

___ Permit Signal Maintenance Transaction (PSMT)

___ Form FIN 400

___ To address specific signal permit situations, the following Forms (not included in this

package) are also available:

- Form SM-00002: Agreement for the Maintenance and Operation of A Traffic

Control Signal On City-owned Property.

- Form SM-00003: Application to Purchase Traffic Control Signal Equipment for Use

On State-Owned Signals.


Control Signal at Entrances to Schools.

- Form SM-00005: Permit for the Maintenance and Operation of A Traffic Control

Signal on State-Owned property.


Control Signal on Village-owned property.

- Agreement for transferring ownership of Traffic Control Equipment.

All Signal Permit Information (Forms, Contacts, etc) can be found on the Intradot- Signals

page. For further information, please contact your regional signal permit coordinator.

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Signal Permit Process

Applicant completes and submits two signed copies of the appropriate Signal Maintenance

Agreement (Permit), Certificate of Liability Insurance (NYSDOT PERM 17) along with a

check of $5,500 to cover expenses related to acceptance testing, equipment, software and

shipping/handling.

See instructions for filling out FORM SM-00001 (rev 3/3/14).

The regions need to make sure that the Certificate of Insurance (COI), when required, be

submitted prior to the signal being turned on.

Application is evaluated, approved and signed by the RTE, and a Signal Permit issued.

One (1) original Permit retained by Region.

One (1) original Permit returned to Permittee.

One PSMT Form sent to Main Office Miscellaneous Revenue along with

a FIN 400 and attached check.

Region creates new signal location and save digital copies of all documents (PSMT,

executed permit application, check, FIN 400, and insurance certificate in Cartegraph

(CG).

Region opens a CG Work Order for the MO Signal Section requesting an assembly

(Signal Cabinet and Controller) for specific Permit # and Signal#.

MO Signal Section verifies that all required documentation is in CG, assigns an

assembly to Permittee (moves serialized equipment into the permit signal record) and

coordinate shipping of equipment to the proper regional signal shop.

Region delivers assembly to Permittee or their authorized Contractor. If other than the

MO assigned equipment/assembly is used for the specific permit signal, the region

will immediately update the CG records (move/transfer/equipment). It is important to

keep CG records up to date for proper documentation and auditing purposes.

Region submits one PSMT Form to MO Miscellaneous Revenue as soon as the permit

signal is “Turned-On”

Region updates CG signal permit record with an electronic copy of the PSMT Form.

Region updates CG signal permit record when a new Insurance Certificate is issued.

These certificates need to be kept up to date.

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Regional Signal Permit Coordinators

NAME PHONE FAX

ALBANY

Region 1

Mark Pyskadlo

NYSDOT, TE&HS

50 Wolf Road – 1S50

Schenectady, NY 12305

(518) 457-5283 (518) 457-4640

UTICA

Region 2

James Lee

NYSDOT, TE&HS

207 Genesee Street 10th

Fl

Utica, NY 13501

(315) 793-2474 (315) 793-2720

SYRACUSE

Region 3

Elizabeth Parmley

NYSDOT, TE&HS, 4th

Fl.

333 E Washington St,

Syracuse, NY 13202

(315) 428-4382 (315) 428-4311

ROCHESTER

Region 4

Richard Lovelace

NYSDOT, TE&HS

1530 Jefferson Road.

Rochester, NY 14623

(585) 272-3470 (585) 340-2406

BUFFALO

Region 5

Angelo Borgese

NYSDOT, TE&HS

125 Main Street

Buffalo, NY 14043

(716) 847-3262 (716) 847-3973

HORNELL

Region 6

Amy Storer

NYSDOT, TE&HS

107 Broadway

Hornell, NY 14843

(607) 281-4219 (607) 324-2663

WATERTOWN

Region 7

Aaron Docteur

NYSDOT, TE&HS

317 Washington St 9th

Fl

Watertown, NY 13601

(315) 785-2327 (315) 779-3003

POUGHKEEPSIE

Region 8

John Simonson or Sean

Alger

NYSDOT, TE&HS

4 Burnett Boulevard

Poughkeepsie, NY 12603

(845) 437-3376 (845) 437-3395

BINGHAMTON

Region 9

Craig England

NYSDOT, TE&HS

44 Hawley Street

Binghamton, NY 13901

(607) 721-8082 (607) 721-8057

LONG ISLAND

Region 10

Eric Huckstadt

NYSDOT, TE&HS

140 Nicon Ct.

Hauppauge, NY 11788

(631) 904-3008 (631) 904-3039

MAIN OFFICE

Traffic Signal

Section

Rufus Banks

NYSDOT; Traffic Signals

50 Wolf Road; POD 5-2

Albany, NY 12232

(518) 485-2827 (518) 457-1780

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INSTRUCTIONS FOR FORM SM-00001

Application And Permit To Install And Operate A Traffic Control Signal On State Owned Property

Top Portion of Page 1:

A. Enter the study number, file number, state police having jurisdiction to the location of the property and the

county where the property is located.

B. Enter Permit Account Number. This number is a five digit number beginning with the region number ("0"

for Region 10). The remaining four numbers are assigned consecutively from the region's log of permit

numbers. To further identify the type of permit, the letter "SM", followed by a dash, are to be added before

the five digit number. (E.g. SM-32516).

The log of permit numbers should be kept in an orderly manner with easy accessibility for co-workers and for

auditing purposes.

For an existing permit, the current five digit permit number should be retained only when a permit is being

updated and it is being issued to the same Permittee for the same property and same signal. In these cases, the

only change on the permit might be the fee. A new five digit permit number should be used in all other cases,

including a new occupant, and a change in the signal.

C. Enter Highway Identification. This is the full name of the highway and/or code associated with the

highway.

D. Enter the Location. This is the address of the property where the signal will be installed.

E. Enter the Signal Number. The signal identification number must be filled in.

F. Enter the name and mailing address of the Permittee. The name should be the same as the one used under

"Acceptance". The mailing address should be the address where the Permittee requests the billings to be

sent.

Provisions

Provision #3: Collect the fee amount for all necessary traffic signal hardware, software and testing, to be paid

in the form of a check or money order payable to the “NYS Department of Transportation” once application

for the Highway Work Permit has been submitted. Use FIN 400 to record transaction. (see sample)

Provision #9: This is the annual signal maintenance fee amount. Payment commences when Signal is

activated.

Provision #12: This is the minimum insurance coverage per occurrence for property damage and/or personal

injury, including death. Signal will not be turned on until proof of insurance is received.

Acceptance Sheet:

Enter name and phone number for future contact with Permittee.

Enter the Federal Identification number of the business/corporation.

The Permittee(s) must sign the permit where indicated.

Individual and/or Corporation Acknowledgments: The Permittee’(s) signature(s) must be notarized. Both the

individual and corporate notary acknowledgments must be completed when the permit is taken with the

corporation or partnership and the individual. One notarized acknowledgment will not suffice for the two

signatures even though they are the same.

Recommended: After obtaining the Permittee'(s) signature(s), the permit must be signed and dated by the

Regional Signal Permit Coordinator to indicate his/her recommendation for approval by the Regional Traffic

Engineer.

Approved: Regional Traffic Engineer reviews and indicates approval with signature and date.

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(FORM SM-00001)

(Revised 03/3/14)

NEW YORK STATE DEPARTMENT OF TRANSPORTATION

OFFICE OF TRAFFIC SAFETY AND MOBILITY

APPLICATION AND PERMIT TO INSTALL AND OPERATE

A TRAFFIC CONTROL SIGNAL ON STATE-OWNED PROPERTY

Study Number:

File:

Troop:

County:

Permit Account Number: ____________________________ Signal No.: _______________

Highway Identification: ________________________________________________________

Location: ____________________________________________________________________

PERMISSION IS HEREBY GRANTED

To ___________________________________________ (hereinafter referred to as Permittee)

Address ____________________________________________________________________

To use and occupy the State-owned property at the above-listed location only for the purpose of installing a

traffic control signal at said location subject to the following conditions:

1. This permit shall not be assigned or transferred without the prior written consent of the Commissioner

of the Department of Transportation (Department). The permittee shall notify the Department 30 days

prior to the sale of the property identified above at which the traffic control signal has been installed

and shall inform the buyer of the property of the existence of this permit. The permittee shall be

responsible for the terms of this permit until such time as a new permit is issued.

2. The initial installation work and each successive time of entry on the State highway right-of-way for

the performance of modifications and replacements required in Item 7 below or other work on the

above described traffic control signal may require securing a separate and distinct “Highway Work

Permit” for each and every such entry and work, pursuant to Section 52 of the Highway Law.

In order to receive the “Highway Work Permit,” the Permittee is required to obtain a Surety Bond

(Performance) and Protective Liability Insurance [as described on and certified by a current NYSDOT

PERM 17 form].

3. The Department shall provide the Permittee with the ancillary traffic signal control equipment (i.e.,

signal cabinet, signal controller, detector cards, etc.) and the Permittee shall pay the Department a fee

of $5,500.00 in the form of a check or money order payable to the “NYS Department of

Transportation” and submitted to the Department’s Regional Traffic Office, upon application for the

Highway Work Permit.

In addition, if the Department determines that the new traffic control signal must be interconnected

with an existing State traffic control signal, such interconnection must be made by the Permittee at its

expense.

In order to provide efficient repairs and minimize downtime, the Department may replace any

component of the traffic control signal with components of equal quality.

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4. All traffic control signal equipment covered by this permit, including, but not limited to, signal poles,

signal heads, signs, signals indications, etc, shall conform to the National Manual on Uniform Traffic

Control Devices (MUTCD) as well as the New York State Supplement, and no such equipment shall

be installed without the prior written approval of the Department. The timing of traffic control signals

shall be specified by the Department.

5. All work required to provide for the installation of the traffic control signal authorized by this permit

shall be performed under the supervision and to the satisfaction of the Department.

6. After construction and installation of the traffic control signal by the Permittee and after any major

modifications and/or replacements conducted by the Permittee, the permit area must be restored to its

original condition. If the permit is revoked, and should the Permittee fail to restore the site, the

Permittee shall reimburse the State for any and all costs incurred by the State for the restoration of the

permit area.

7. The Permittee shall be responsible for any future improvements, major modifications and/or

replacements to the traffic signal control equipment which is determined necessary by the

Department. Major modifications and replacements include, but are not limited to, changes in the

signal operation and/or signal equipment due to revised inter-sectional geometry resulting from

changes in the Permittee’s site operations and/or traffic flow patterns. In addition, the Permittee shall

not deny another party the use of the traffic signal to gain access to the state highway from another

approach if required by the Department on such terms and condition s that the Department deems

appropriate state.

8. The Permittee or its successors hereby grants permission to the State and its agents to enter upon and

perform work on his property for the purpose of performing maintenance on the traffic control signal.

9. The Department will maintain the traffic control signal for an annual fee of $1,251.62 to be paid to the

Department by the Permittee. The first payment is due at the time the signal is placed in operation.

The annual fee is calculated by the Department by computing the average annual cost of maintaining a

traffic control signal under the jurisdiction of the Department or the annual contract cost per traffic

control signal charged to the Department under a Traffic Control Maintenance Contract.

The annual fee must be paid by check, bank cashier's check or money order payable to "NYSDOT"

and mailed or delivered to the address indicated on the invoice. The Permittee understands that if the

annual fee is not paid within thirty (30) days from the invoice date, interest, penalties and collecting

fees will be imposed pursuant to the provisions of the State Finance Law.

The Permittee agrees that the annual fee may be revised periodically to reflect the Department’s

normal maintenance cost for traffic control signals as provided in Section 1681(c) of the Vehicle and

Traffic Law.

The Permittee understands that energy or electrical costs are separate and are the Permittee’s

responsibility.

10. The Permittee shall be responsible for any improvements on its property that are associated with the

installation and operation of the traffic control signal. It is the responsibility of the Permittee to notify

the State immediately of any unsafe or hazardous conditions that would affect continued occupation

of property that are actually or constructively known by Permittee.

11. The Permittee shall indemnify and save harmless the State for claims, suits, actions, damages and

costs of every name and description attributable to the traffic control signal and such indemnification

shall not be limited by reason of enumeration of any insurance coverage provided herein. The

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Permittee agrees, upon being requested to do so, to assume the defense and to defend at its own costs

and expense any action brought at any time against the Department or the State in connection with

any such claims, suits and actions.

12. Liability Insurance. Permittee seeking a permit to install a traffic signal permitted under 17 NYCRR

section 125.11, shall be required to have a commercial general liability insurance policy with limits of

liability of not less than $5,000,000 per claim/occurrence. Policies of insurance shall be endorsed to

provide coverage to “The People of the State of New York and/or the Commissioner of

Transportation and all employees of the State Department of Transportation” for claims arising from

the permitted work. The required insurance shall be documented by means of a certificate of

insurance, upon a form satisfactory to the department, furnished by the permittee before the

commencement of any work/operations. Self-insurance is permissible from municipalities, federal

agencies, public authorities, public benefit corporations, public utilities, transportation corporations

and railroads, by use of an undertaking agreement acceptable to the department. Self-insurance from

other permittees in lieu of the required liability insurance may be accepted upon satisfactory proof that

permittee has the financial resources and an established self-insurance program to adjust and pay

liability claims.

Protective liability insurance requirements. In addition to the requirement to provide general

liability coverage, if the estimated value of permitted work in state right-of-way is $250,000 or more

Permittee is required to provide protective liability insurance. Such policy of protective liability

insurance shall be issued to, in the name of and covering the liability of the "the People of the State of

New York and/or the Commissioner of Transportation and all employees of the State Department of

Transportation." Such policy shall carry limits of liability of not less than $1,000,000 per

occurrence/$2,000,000 aggregate. The policy shall be written for the permitted project and shall be

kept in force at the expense of the permittee for the duration of the project. The policy shall provide

primary coverage to the State of New York against any claim arising in any way from the permitted

work within the area covered by the permit.

Workers’ compensation insurance requirements. As a condition of the issuance of any permit

permittees are required to furnish proof that is duly subscribed by an insurance carrier, that

compensation for all employees has been secured as required by Section 57 of the Workers’

Compensation Law of the State of New York, or that the person or persons performing such work are

exempted from the requirements of that law.

13. Permittee is responsible for assuring that its occupancy shall be in compliance with any and all

applicable Federal, state and local laws, ordinances, codes, rules and regulations affecting the use of

the property for the purpose recited above.

14. This permit may be cancelled by the State on thirty (30) days written notice except for cause in which

event cancellation may be made on ten (10) days written notice.

15. The person executing this permit on behalf of the Permittee hereby certifies that the person has full

authority to execute this permit and, if the Permittee is a municipal board, the person has annexed

hereto a certified copy of a resolution by such body authorizing that person to execute this permit.

16. If any of the provisions of this permit are held invalid, such invalidity shall not affect or impair other

provisions herein which can be given effect without the invalid provisions, and to this end the

provisions of this permit are severable.

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ACCEPTANCE:

In consideration of the granting of the Permit, the undersigned accepts all of the above terms, conditions and

provisions.

Permittee Contact Name and Phone Number:

___________________________________________________________________________________

Permittee Billing Address:

___________________________________________________________________________________

Fed. I.D. No.: ____________________ Signed: ________ _________________________

Printed name: ____________________ Title: ___________________________________ (If Applicable)

STATE OF NEW YORK )

) SS:

COUNTY OF ________________ )

On the _______ day of ____________ in the year _______ before me, the undersigned, a

Notary Public in and for said State, personally appeared________________________________, (Acceptee’s

Name) personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose

name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the

same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s),

or the person upon behalf of which the individual(s) acted, executed the instrument.

__________________________________

(Notary Public)

RECOMMENDED: ______________________________________ ___________________

Regional Signal Permit Coordinator Date

APPROVED: Commissioner of Transportation for the People of The State of New York

By ______________________________________ ___________________

Regional Traffic Engineer Date

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CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND

CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE

DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE

POLICIES BELOW.

INSURERS AFFORDING COVERAGE NAIC #

INSURED INSURER A: INSURER B: INSURER C: INSURER D:

COVERAGES

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR

CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES

DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR

LTR

ADD’L

INSRD TYPE OF INSURANCE

POLICY NUMBER POLICY EXPIRATION

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY) LIMITS

GENERAL LIABILITY EACH OCCURRENCE

$

COMMERCIAL GENERAL

LIABILITY

DAMAGE TO RENTED

PREMISES (Each

occurrence)

$

CLAIMS

MADE

OCCUR

MED. EXP.

(Any one person)

$

PERSONAL & ADV.

INJURY

$

GENERAL AGGREGATE

$

GEN’L AGGREGATE LIMIT APPLIES

PER:

PRODUCTS-COMP/OP

AGG

$

POLICY

PROJECT

LOC.

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT

(Each accident)

$

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

BODILY INJURY

(Per person)

$

BODILY INJURY

(Per accident)

$

PROPERTY DAMAGE

(Per accident)

$

GARAGE LIABILITY

AUTO ONLY -

EACH ACCIDENT

$

ANY AUTO

OTHER THAN

AUTO ONLY

EA.

ACC.

$

AGG. $

EXCESS/UMBRELLA LIABILITY

EACH OCURRENCE

$

OCCUR CLAIMS

MADE AGGREGATE

$

$

DEDUCTIBLE

$

RETENTION

$

WORKERS COMPENSATION AND EMPLOYERS’

LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

If yes, describe under SPECIAL PROVISIONS below.

WC OTHER $

STATUTORY

LIMITS

E.L.

EACH ACCIDENT

$

E.L. DISEASE-

EACH EMPLOYEE

$

E.L. DISEASE-

POLICY LIMIT

$

OTHER

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL

PROVISIONS. The People of the State of New York are added as Additional Insured with respect to the General Liability Coverage for

Signal Permit Account Number SM-

CERTIFICATE HOLDER CANCELLATION

NEW YORK STATE DEPARTMENT OF TRANSPORTATION

OPERATIONS DIVISION, TRAFFIC SIGNAL SECTION

50 WOLF ROAD, POD 4-2

ALBANY, NY 12232

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL TEN (10)

DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT

FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE

INSURER, ITS AGENTS OR REPRESENTATIVES.

AUTHORIZED REPRESENTATIVE

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F Form PSMT (rev 1/14) MEMORANDUM

DEPARTMENT OF TRANSPORTATION

TO: MO Revenue Unit; 50 Wolf Rd; POD 5-2; T: 518.457.3346 / F: 518.457.4073

FROM:

SUBJECT: Permit Signal Maintenance Transaction (PSMT)

DATE:

Permit No: Signal Number:__________________ Type of Permit: __01- Private __02- City __03- Mitigated (HWY) __04- School Does this Permit Replace a Previous Permit? YES List previous permit number: (Transferred)

NO (New / Update)

Signed Contract Attached? (New & Transferred)

Signed Transfer of Ownership (to NY State) Attached? (Mitigated, Cancelled)

Ins. Cert. Attached? (New & Transferred)

Check and FIN 400 Mailed to MO Revenue; 50 Wolf Rd; POD 5-2? (New & Replacement)

Permit Signal Turned On? Effective Date of Transaction: Accounting Action to be Taken: Add Permit to Billing System But Don’t Bill Annual Maintenance Fee Yet Start Billing Annual Maintenance Fee

Cancel Permit from Billing System

Permittee Information: Permittee Name: Address: Billing Address:

Remarks:

Signature: Date:

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