TOWN OF BROOKHAVEN
HIGHWAY DEPARTMENT
1140 OLD TOWN ROAD, CORAM, NEW YORK 11727–3728
DANIEL P. LOSQUADRO
SUPERINTENDENT OF HIGHWAYS
PHONE: 631–451–9200
FAX: 631–732–2584
TREE INSPECTION REQUEST FORM
PLEASE FILL OUT AND RETURN. FAILURE TO COMPLETE THIS FORM IN ITS ENTIRETY WILL DELAY OUR
INSPECTION OF THE TREE(S).
I hereby request that the Town of Brookhaven Highway Department inspect the tree/trees located:
□ In front of your home
□ On the side of your home - Street Name _______________________
Home Address Including Hamlet: _____________________________________________________________
Nearest Cross Street: ________________________________________
Reason for Inspection:
________________________________________________________________________________________
________________________________________________________________________________________
Are Wires going through the tree/trees? Yes_____ No_____
SPRINKLER WAIVER (Please check appropriate box)
_______ I do not have an underground sprinkler system, therefore I will not hold the Town of Brookhaven or the
Town of Brookhaven Highway Department liable for any sprinkler damage.
_______ I do have an underground sprinkler system and understand that should the Highway Department remove
the tree/s and grind the stump/s it is possible that there could be damage to my underground sprinkler system in the
vicinity of the removal. I hereby agree to hold the Town of Brookhaven and the Town of Brookhaven Highway Department
harmless for any damage that may occur during the tree removal and stump grinding processes. I further agree to accept
responsibility for any damage that is done to the sprinkler system and will undertake repair to the system at my own
expense.
You will receive written notification advising you of the results from our inspection.
___________________________________________
Property Owner (please print)
___________________________________________
Address
___________________________________________
Telephone #
___________________________________________
Signature
___________________________________________
Date
click to sign
signature
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