Form Hc-91 - Permission To Perform Contract Work On Private Land

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HC 91
FEDERAL-AID LOCAL PROJECT
(12/10)
PERMISSION TO PERFORM CONTRACT WORK ON PRIVATE LAND
PROJECT IDENTIFICATION NUMBER: ________________
FROM: ________________________________________ TO:_______________________________________
LOCATION:
New York County of: ________________________________
The undersigned owner(s) of private land(s) that is/are located at the address(es) listed below:
Property owners address (include mailing address if different)
hereby grant permission and give consent to _________________________________ or its contractors or
designees, to enter onto the property identified above in connection with the above referenced contract for the
purpose(s) identified below. This permission is granted with the understanding that such work shall be limited to as
shown in the attached or an area within ____ Feet of the public right of way line to:
RE-ESTABLISH
APPROACHES
TO
REPLACE ELECTRICAL, GAS, TELEPHONE, WATER, OR
1
3
PRIVATE LAND (DRIVEWAYS/WALKWAYS)
SEWER UTILITY CONNECTIONS TO PRIVATE PROPERTY
2
2
PLANT TREES & SHRUBS
REMOVE UNSOUND OR HAZARDOUS TREES
1
GRADE AND RE-ESTABLISH TURF
January
January
The work is scheduled to occur between the months of ______________, 20__
and _____________, 20___.
February
February
The Engineer will contact the property owner before entering the private property if these dates change. The
property
owner
may
revoke
permission
at
any
time
by
contacting
the
Engineer,
________________________________ at _______________________________________________________.
The property owner(s) are responsible for maintaining the improvements to be constructed. The undersigned
property owner(s) agree that _________________________________ or its contractors or designees, shall not be
liable for the maintenance of such improvement, nor liable for damages in connection therewith after the
completion of the work. The undersigned property owner(s) waives any right to compensation for tree removals in
consideration of the property improvements performed on the private property. The undersigned property owner(s)
agree to release and hold harmless __________________________________ or its contractors or designees
from any liability or damages which may arise after the completion of the work performed.
Property Owner(s):
Printed Name
Signature
Date
Property Owner(s):
Printed Name
Signature
Date
In the presence of:
Witness(s):
Name/Title
Signature
Date
Witness(s):
Name/Title
Signature
Date
NOTES:
1. Per Section 54-A of the State Highway Law
2. Per Sections 19 and 45 of the State Highway Law
3. Per Section 10 of the State Highway Law

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