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4328 State Route 19, Silver Springs, NY 14550Todd Gadd - Superintendent of HighwayPhone (585)786-8955Fax (585)786-3297
(please explain scope of work and attach sketch of proposed work)
in accordance with the map and plan hereto attached and pursuant to the conditions and regulations. The undersigned will obtain any other consents or permits that may be necessary to accomplish the purpose forth herein.
to proceed as set forth and represented in accordance with the map and plan hereto attached and pursuant to the conditions forming a part hereof; to wit;
1. This permit shall not be assigned or transferred without the written consent of the County Superintendent of Highways.2. The work authorized by this permit shall be performed in a manner satisfactory to the County Superintendent of Highways. 3. The County Superintendent of Highways shall be given one (1) week notice by said permitee of the date when it intends to begin the work authorized by this permit, and prompt notice of its completion.4. The said permittee shall be responsible for all damage resulting in bodily injury including death and/or property damage liability due to activities of the permittee, its contractors, sub-contractors, of either both agents or emplotees in connection with any act or omission hereunder, and does hereby expressly agree to indemnify and save harmless the County of Wyoming from any and all responsibility or liability arising out of, or resulting from, any act or omission hereunder.5. The said County Superintendent of Highway reserves the right to revoke or annul this permit at any time should the said permittee fail to comply with the terms and conditions upon which it is granted.6. It is understood that should future reconstruction or use of the Highway make changes necessary in the proposed facilities covered by this application and permit, the permittee shall, upon reasonable notice from the County Superintendent of Highways, make such changes at its own expense within such time as may be agreed upon.7. Traffic shall be maintained by the applicant on the said section of highway while the work is in progress and until its final completion.8. Upon completion of the work authorized by this permit, the highway shall be left in a neat, orderly, and as good condition as before commencement of the work.
(day of month
* Permittee to sign below *
In consideration of the granting of the within permit, the undersigned hereby accepts the same subject to the conditions and regulations therein set forth.
(day of month)
By electronically signing this form you agree to this authorization.
Note: Form may be printed and mailed to our offices at Wyoming County Highway Department: 4328 State Route 19, Silver Springs, NY 14550 with appropriate payment fee.
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