Please complete the following information and Print

Please complete the following information and
Print, Sign, Date and Mail to:

Incorporated Village of Farmingdale
PO Box 220 361 Main Street
Farmingdale, NY 11735
(516) 249-0093
www.FarmingdaleVillage.org

PERMIT APPLICATION
WATER SUPPLY (CHAP. 102)
ROAD OPENING (CHAP. 86)

Name of Applicant:

Street Address:

SECTION:

BLOCK:

LOT:

Address of work to be done:

Name of Contractor:

Contractor's Phone Number:

Contractor's Address:

Water Supply Installation 1 Inch Meter	$810.00	MCR#	Acct. F2625
Road Opening Permit Fee	$25.00	MCR#	Acct. F2144
Trenching Fee	$6.00 per sq. ft.	MCR#
Performance Deposit
Signature of Applicant _______________________________________________			Date: _______________
Approved: _______________________________________________			Date: _______________
Please note that we will need a performance bond in the amount of $5,000.00 from your plumber.