Petition For A New Revocable Consent New York City Department of Transportation Division of Franchises, Concessions and Consents 40 Worth St, 9th Floor South New York, NY 10013 Telephone: (212) 442-8040 Date of Submission: Name of Petitioner: Address of Petitioner: Petitioner’s Contract Manager: Contact Person: (e.g.: Attorney, Engineer or Architect during the petition process) Address of Contact Person: (This is the person who will handle payments to the City, insurance and security deposit after the consent is granted) Contract Manager’s Telephone Number: Contract Manager’s E-mail Address: Nature of Petitioner’s Business: Contact Person’s Telephone Number: Contact Person’s E-mail Address: The above named petitioner requests a revocable consent from the Department Of Transportation construct, maintain and use: (fill in Type of structure (s) description and location (s) Notes: Use attachments if additional space is required. Petitioner must submit photos of existing conditions for above ground structures, whether subject structures are in place or not. Property Information: 1. The premises affected by the proposed structure (s) are: (check applicable box) Owned by petitioner (if this box is checked, submit copy of deed) 2. Primary property benefited Address: Block and Lot: Owner: Leased by petitioner (if this box is checked, submit consent of the owner along with copy of the deed and lease) Secondary property benefited Address: Block and Lot: Owner: (if only one property, indicate N/A, if more than two, attach additional information to this form) 3. Community Planning District (Community Board) Number: 4. City Council Member Name: American LegalNet, Inc. www.FormsWorkflow.com Petitioner Information: The petitioner is (check applicable box) A domestic corporation. (Incorporated in the State of New York) A corporation organized under the laws of the State of and duly authorized to do business in the State of New York. A general partnership. An individual. Other (fill in description): Note: Petitioner must attach a copy of Certificate of Incorporation with appropriate seal or Certificate of Partnership. The Petitioner will use the requested structure (s) for the following purpose (s): Petitioner Agrees To The Following Terms Of Petition Acceptance By Dot: 1. Petitioner covenants that the revocable consent, if granted, will be for the private use of the petitioner. 2. Petitioner warrants that all taxes due to the City of New York have been fully paid. 3. For all above-ground structures, except planters: Upon notification by the Department that approvals have been secured from all agencies having jurisdiction, the petitioner will submit all necessary materials and make a presentation to the Art Commission. Petitioner agrees to comply with this requirement within 45 days after such notification by the Department. 4. Petitioner agrees to pay, within 30 days of its receipt, an invoice for advertising fees for two notices in each of two newspapers to inform the public of the hearing on agreement terms. Hearings are held pursuant to Section 371 of the New York City Charter. 5. The petitioner agrees to execute (sign) the revocable consent agreement and return it to the Department within 15 days of its receipt. Failure to do so may result in denial of consent. 6. Petitioner acknowledges that the final agreement will include provisions for yearly compensation to the City, maintenance of a security deposit and filing of proper insurance documents. Petitioner agrees to submit a payment of security within 30 days of notification by the Department that such item is due. Petitioner agrees to maintain a certificate of insurance on the structure for which consent is to be granted. Additional information, if any: American LegalNet, Inc. www.FormsWorkflow.com Wherefore, Petitioner affirms that he/she will conform to the terms of petition acceptance listed above, or if not, he/she will before 10 days prior to any and all such due dates, request from the Department in writing, an extension of the due date(s). Reasons for the extension must be included. The petitioner understands that, if these terms and conditions are not met, the Department will, without further notice, void the petition. If a petition is voided, a new petition must be submitted along with the required petition fee. Petitioner acknowledges that the Department may, in its sole discretion, allow exceptions to the requirements contained in this paragraph. Wherefore, Petitioner respectfully requests that the revocable consent be granted as aforesaid. By Petitioner’s Signature Print Name of Signatory Print Title of Signatory Subscribed and sworn to before me this day of , 20 Notary Public American LegalNet, Inc. www.FormsWorkflow.com I, A duly licensed professional engineer or registered architect with an office at do here with submit plans for a revocable consent for at (location) (signature) New York State License Number Telephone Number Seal Authorization of Petitioner I, , hereby authorize the above named party to submit the above noted plans pursuant to my application for a revocable consent. (signature) (date) Click here if you wish to obtain a voter registration form. Government services are not conditioned on being registered to vote. A voter registration form can also be obtained at http://nyc.gov/html/misc/html/register.html, or by calling (212) 868-3692. American LegalNet, Inc. www.FormsWorkflow.com