HomeMy WebLinkAbout41535 Route 25 26685
CHASE
NA-noML•GRID 411x. Bank,NA bom
175E OLD 666ifNR RD 1-1-210
OPS BLD TIRW FL1/21/14
-
HICKSVILLE,NY 11801
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PAY TO THE ** ** *17'OtiOQ
ORDER OF
Town of SOUtI10ld .
One Hundrert Seventy and not100*** DOLLARS
MEMOWMOFUMllt� P
T10156272�,. "
11'0 2668 S11 1:0 2 10000 2 0: 69008 5860 211'
2) 41535 Main Rd Peconic Premises Address
3)
4) Open a-4'x4' bellhole on the E/s of Route 25,approx.545' S/o Peconic Ln,to install a
gas service.
5)
6)
7) tidal wetlands? *Yes No_X
*If yes,other Town permits may be required.
Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
J c ke' 94,L'`
Signature of Applicant
Date;01/f7/14
)posed excavation and relationship to adjoining premises or
j I description of layout of excavation.
licenses for this project.
ut commence before issuance of a Highway Excavation Permit
Block ,Lot
Completion Date:
Completion Date
«compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
12) Insurance Coverage(Attach Copy)