New York City Department Of Transportation Division Of Franchises, Concessions And Consents 55 Water Street, 9th Floor New York, NY 10041 (212) 839-6550 Petition Form For A New Revocable Consent Date of Submission CONTACT INFORMATION Petitioner Name EIN # Address Contact Person e.g. attorney, engineer or architect Address Telephone Email Fax Contract Manager Telephone person who will handle payments to the City, insurance and security deposit after the consent is granted Email Address Fax PETITION DETAILS The Petitioner requests a revocable consent from DOT to construct, maintain and use fill in structure(s) description and location(s). 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. The Petitioner will use the requested structure for the following purpose Additional information, if any 1 of 3 RC-1. Revised 05/27/10 American LegalNet, Inc. www.FormsWorkFlow.com New York City Department Of Transportation Division Of Franchises, Concessions And Consents 55 Water Street, 9th Floor New York, NY 10041 (212) 839-6550 Petition Form For A New Revocable Consent PETITIONER INFORMATION The Petitioner is Check one. If Petitioner is a partnership or corporation, attach a copy of Certificate of Partnership or Certificate of Incorporation with appropriate seal. a domestic corporation incorporated in the State of New York a foreign corporation organized under the laws of the State of authorized to do business in the State of New York and duly a general partnership an individual other, describe Nature of Petitioner’s Business PROPERTY INFORMATION The premises affected by the proposed structure(s) are Check one. Owned by the Petitioner submit copy of deed Leased by the Petitioner submit consent of owner, and copies of deed and lease Primary property benefited Secondary property benefited Address Address Block and lot Block and lot Owner Owner If only one property, indicate N/A for second property. If more than two, attach additional information. Community Board City Council Member 2 of 3 RC-1. Revised 05/27/10 American LegalNet, Inc. www.FormsWorkFlow.com New York City Department Of Transportation Division Of Franchises, Concessions And Consents 55 Water Street, 9th Floor New York, NY 10041 (212) 839-6550 Petition Form For A New Revocable Consent 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, fees, levies, fines and other monies due to the City of New York have been fully paid. 3. 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 City Charter. 4. 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 Public Design Commission. Petitioner agrees to comply with this requirement within 45 days after such notification by the Department. (Note: this requirement is for above-ground structures only). 5. 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 City Charter. 6. 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. 7. 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 and a certificate of insurance within 30 days of notification by the Department that such items are due. 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 Print Name of Signatory Signature Subscribed and sworn to before me this Print Title of Signatory day of , 20 . Notary Public 3 of 3 RC-1. Revised 05/27/10 American LegalNet, Inc. www.FormsWorkFlow.com