Fillable HW 17 Transfer Highway Work Permit Packet (Town of Brookhaven)

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HW 17 Transfer Highway Work Permit Packet (Town of Brookhaven)

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The HW 17 Transfer Highway Work Permit Packet (Town of Brookhaven) form is 2 pages long and contains:

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  • 3 check-boxes
  • 9 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

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Division of Engineering
1 Independence Hill, Farmingville, NY 11738
Phone (631) 451-9090 Fax (631) 716-0572 www.brookhavenny.gov
HW 17 (1)
Daniel P. Losquadro
Superintendent of Highways
HOW TO TRANSFER A HIGHWAY WORK PERMIT
1. Complete Transfer Affidavit. This affidavit must be notarized.
2. Only if bond money is being held in escrow on the permit will it be
necessary to complete the Assignment of Highway Escrow form. If this
form is required, it must be notarized.
3. Insurance Requirements: The Permit Holder/Contractor must furnish the
Town of Brookhaven with a Landlord’s & Owner’s policy or Homeowner’s
Liability policy naming the Town of Brookhaven and Superintendent of
Highways as ADDITIONAL INSURED in the following amounts: $100,000.00
and $300,000.00 personal injury and $50,000.00 property damage. If the
Permit Holder/Contractor already has liability insurance, a certificate
naming the Town of Brookhaven and Superintendent of Highways as
ADDITIONAL INSURED for the same amounts is required.
If you are using the contractor’s insurance, the contractor must provide
the above certificate of insurance and a letter, on company letterhead,
authorizing the applicant/property owner to use the contractor’s
insurance. We must have the original letter. This letter cannot be faxed or
emailed.
4. Submit notarized form(s), insurance certificate and $150.00 fee to
Highway Engineering. Make check, bank check or money order payable to
Town of Brookhaven Highway Dept.
We cannot accept cash, credit or debit cards.
Division of Engineering
1 Independence Hill, Farmingville, NY 11738
Phone (631) 451-9200 Fax (631) 716-0572 www.brookhaven.org
Daniel P. Losquadro
Superintendent of Highways
HIGHWAY WORK PERMIT
TRANSFER AFFIDAVIT
PERMIT # _______________
DATED __________________
The undersigned, being duly sworn, does depose and state as follows:
I am the (owner) (contract vendee) (other_______________________) of certain premises located at
___________________________________________________________________________________,
New York, for which the above Highway Work Permit was issued.
I hereby assume all responsibilities and obligations pursuant to the above Highway Work Permit and agree to
complete all work within the Highway Right of Way in accordance with the Town of Brookhaven specifications.
________________________________ _______________________________________
SIGNATURE PRINT NAME
________________________________ _______________________________________
COMPANY NAME STREET ADDRESS
________________________________ _______________________________________
TOWN, STATE AND ZIP CODE PHONE NUMBER
State of New York)
) ss.:
County of Suffolk )
On the day of in the year 20__ before me, the undersigned, a Notary Public in and for said State,
personally appeared , personally known to me or proved to me on the basis of
satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged
to me that he/she/they executed the same is his/her/their capacity(ies), and that by his/her/their signature(s) on the
instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
__________________________________________
NOTARY PUBLIC
FORM CANNOT BE FAXED OR MAILED;
IT MUST BE HAND DELIVER TO OUR OFFICE.
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HW 17 Transfer Highway Work Permit Packet (Town of Brookhaven)

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Completed 16 July 2020

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