1. law, govt and politics
2. law enforcement
3. highway patrol

VIII. SAMPLE FORMS
A. Sample Highway Work Permit Application Form
B. Sample Certificate of Liability Insurance Form
C. Sample Sight Distance Certification Form
D. Sample Right of Way Monument Certification Form
32
Dutchess County Department of Public Works
626 Dutchess Turnpike
Poughkeepsie, NY 12603
Phone: (845) 486-2925
Fax: (845) 486-2940
rev. 9/06
Highway Work Permit Application
Important information….please read first!
FOR PERMIT ASSISTANCE
Please call 486-2925 for assistance with the permit application process.
To contact this office via mail, our address is:
Dutchess County Department of Public works
Highway Permits - Traffic Safety Division
626 Dutchess Turnpike
Poughkeepsie, NY 12603
Office hours are 9:00 to 3:00 pm, Monday through Friday, to obtain forms, policy manuals, and
specifications.
Permit engineers are available for meetings by appointment only. Please call 486-2925 to schedule an
appointment with a permit engineer for your area.
PERMIT APPLICATION REVIEW
All work must be done in accordance with the “Policy & Standards for Access and Utility Work on County
Highways” (Highway Work Permit Policy Manual).
A permit engineer will contact you concerning application status within 2-3 weeks after a complete
application is on file.
The applicant for temporary or permanent driveways must be property owner. Proof of property
ownership may be required at time of application.
Application is not complete until all materials are submitted. Please refer to Section 7 of the Highway
Work Permit Policy Manual.
PERMIT APPLICATION FEES
Permit application fees may be in the form of a personal check, certified check, bank check or money order
made payable to Dutchess County Commissioner of Finance. Cash will not be accepted.
Please refer to Fee Schedule for permit application fee.
The permit application fee is NON-REFUNDABLE. Permit application and fee must be submitted
together.
SECURITY DEPOSITS
Security deposits MUST be provided by the Permittee and be in the form of a CERTIFIED or BANK
CHECK made payable to Dutchess County Commissioner of Finance. Personal checks will NOT be
accepted for security deposits.
Please refer to Fee Schedule for security deposit amounts.
Security deposit will be refunded to the Permittee only upon acceptance by Dutchess County DPW of
completed work.
OTHER CONTACTS:
For work on a town road, contact the highway department for the municipality (town/village) the road is
located in.
For work on a state highway, contact:
New York State Dept. of Transportation, Traffic & Safety Group
4 Burnett Boulevard
Poughkeepsie, NY 12603
* * * COMPLETE APPLICATION ON REVERSE * * *
* * * PLEASE COMPLETE AND SIGN * * *
Name of Applicant____________________________________________Phone:_________________
(Applicant must be property owner)
MailingAddress_____________________________________________________________________
Street
Town
State
Zip
County Route No.__________ Town / Village ____________________________
Address of proposed work:____________________________________________________________
Tax Parcel ID #__________________________________________________
Type of Application (see Fee Schedule):________________________ Fee:____________________
Brief Description of Work :____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Location of Work: On the N / S / E / W side of County Route_________ and also being ____ feet /
miles N / S / E / W from ___________(nearest intersecting road/street). Additional directions or
landmarks:___________________________________________________________________________
All authorized work including restoration shall be completed within one year from permit issue date. If work cannot be
completed by the date specified, applicant must apply for renewal of the permit. Dutchess County Department of Public Works
reserves the right to grant or deny a permit renewal request.
The Permittee shall assume all liability for and save the County, its agents and its employees, harmless from any and all claims
for damages, action or causes of action arising out of the work to be done herein and the continuing uses by the Permittee,
including but not limited to the placing, constructing, reconstructing and maintaining utility under this application.
(I, We), the undersigned, accept the terms and conditions of the Highway Work Permit Policy Manual established by Dutchess
County DPW and will perform all work to the satisfaction of the Commissioner of Dutchess County Department of Public
Works.
APPLICANT SIGNATURE
DATE
Permit application is valid for 60 days. Upon expiration of the 60 day period, a new application and fee may be required at the
discretion of the Dutchess County Department of Public Works.
OFFICE USE ONLY
Application reviewed by:________________
Application complete (date, initials):__________________
D.M.I. (For sign permit) _______
APPLICATION STATUS (Date, Initial):
Approved__________ Denied____________
Cancelled__________
PERMIT
NO:_________
Dutchess County Department of Public Works
Highway Work Permit Sight Distance Certification Form
Project Information
Highway Work Permit Number: _________________
County Route Number: ____________________ Road Name: __________________
Municipality: (Town/Village/City) of ______________________________________
Driveway Address: _____________________________________________________
Tax Parcel Number: _________________________________
Highway Posted Regulatory Speed: _______mph
or
85th Precentile Speed: _______mph
Certifying Agent
Engineer/Surveyor Name: _________________ New York State Lic. Number: ________
Address: _________________________________________________________________
Sight Distance Measurements
Stop Line Sight Distance-Left (SLSD-Left): ____________ ft.
Stop Line Sight distance-Right (SLSD-Right): ___________ft.
Turning Sight Distance (TSD): __________ft.
Stopping Sight Distance (SSD): __________ft.
Date Measurements were taken: ________________
Certification
I, ______________________ hereby certify that the sight distance measurements provided herein
were taken by me personally upon completion of the permitted work and that they were measured
in accordance with the current Dutchess County Department of Public Works ‘Policy and Standards
for Access and Utility Work on County Highways’ (Policy), and that the measurements meet or
exceed the required sight distances established by the ‘Policy’.
Signature with Seal
Date
THIS PAGE INTENTIONALLY LEFT BLANK
Dutchess County Department of Public Works
Highway Work Permit Right of Way Boundary
Monument Certification Form
Project Information
Highway Work Permit Number: _________________
County Route Number: ____________________ Road Name: __________________
Municipality: (Town/Village/City) of ______________________________________
Filed Map Number: _____________________________________________________
Subdivision Name: _____________________________________________________
Tax Parcel Number of Each Lot with County Highway Frontage: (use addl. paper if required)
Certifying Agent
Surveyor Name: _________________ New York State Lic. Number: ________
Address: _________________________________________________________________
Certification
I, ______________________ , being a duly licensed surveyor in New York State, hereby certify that
boundary monuments have been installed to delineate the County highway right of way in accordance with
the standards of the Dutchess County Department of Public Works and such monuments have been installed
accurately pursuant to the Filed Map and/or deeds filed in relation to the properties listed hereon.
Signature with Seal
Date
THIS PAGE INTENTIONALLY LEFT BLANK