9.F.1  I  APPLICATION for  York State  coPY.  New  Department of Transportation  Permit for the Temporary Use of State-Owned Property  Inquiry #  IWWe hereby make application to temporarily use and occupy aj portion of publicly-owned lands (including access rights) We understand that this is an application, not a permit; and that this application is not a commitment by the Department ofTransportation that a permit can or will be approved for the requested temporary use and occupancy. IWe understand that this requested use is temporary in nature and that ifat temporary use and occupancy permit is IWe understand that permanent improvements are prohibited if they cannot be removed at the time the permit is revoked or cancelled; and the conduct, growth, success or continuity of any permittee business activity is not dependent on the use of State property, nor shall the permittee rely on the use of property for such purpose any business activity is IWe understand each year for the duration of the permit, the permittee will be required to pay an annual fee and furnish proof of liability insurance coverage, naming the People of the State of New York, the Department of Transportation, its agents and/or representatives as additional and co-insured parties to the policy to cover any claims for damage or injury  under thej jurisdiction oft the New' York State Department of Transportation.  issued, the permit is revocable upon 30 days' notice.  consistent with the terms of a: 30 day revocable permit.  that occur within the permit area or arise from activities int the permit area.  APPLICANT INFORMATION Ifapplicable: Business Name  Date Apul 17 1022 - Hishacy Speritull  Name(s)  Michaal Kithcast  Taww Wims Highaay  Type of Business Contact Person  LLC  Corporation Michad Kithcat  Partnership  d/bla Muncpalits  Owner of abutting property Mailing Address Billing Address Telephone # E-mail Address PROPERTY LOCATION Town/CityMilage  Other (please specify)  7owr d Wundsk. 124 MoLA Sy WIoe NY13F6S  174 Chapel S+ NINdSE NYIFES P3k dsir NY 13865  607-655- 1645  Cell Phone # GG7- 206- 6567  Wipdsak by@eduatsa  Wdsrr old R+7  County  Bhame  State Highway Route No. Canhy2t27 Between Highway Mile Markers  and  Street Address/Location Wipdsee Sub- Resia enay Approximate size in square feet or acres Dimensions of requested area  610 Old Rt 17 Wundsor Ny 13865  3.0F Fackas  HA-MMN sehismh Na-wh! Southy batwea old R+17 1-86 w8) toperui Na Pout Ch bath HEwestew t easter an) X 1,200 f/-  ROW 575 (12/2021)    APPLICATION for  New York State Department of Transportation Permit for the Temporary Use of State-Owned Property  The following items must be submitted with your application:  Site location map showing the closest cross street(s), mile markers, or other identifiable landmark(s) Sketch/drawing with north arrow, showing: area and dimensions of proposed temporary use and occupancy; approximate location oft the highway boundary; proposed access tot the site; known drainage and existing utilities; and if applicable, existing or proposed structures on the abutting property Available supporting materials such as: site plan, survey for abutting property, plans for proposed  improvements, tax map, etc.  W-9  Copy oft the deed to the owner's abutting property if applicable  DESCRIPTION OF REQUESTED USE/OCCUPANCY Describe intended temporary use of the property.  FEO"S-Gas  oP ase  Paciliy for sepais t aSE at GAAcr tcuit foh bastikaen  garage  4se  Does this request require a permit or approval from another governmental entity?  I NO  YES Name of approving entity Permitapproval required  APPLICANT SIGNATURE: Miskn  de  DATE: W2z/2  Return to:  Office of Right of Way New York State Department of Transportation 44 Hawley Street, Room 1007 Binghamton, NY 13901 Terry.Pritchard@dot.ny-gov  OR E-mail to:  ROW575 (12/2021)