Dumpster Permit Application

OFFICE USE ONLY

DATE APPLICATION RECEIVED:

PERMIT NUMBER:

FEE: $100

PAYMENT INFO:

Information contained herein may be investigated and verified. Any false statement will be cause for refusal and revocation of this permit. It is further understood that applicant wil! conform and adhere to all laws applicable, and such rules and regulations as may be promulgated by the Incorporated Village of East Rockaway regulating and relating to the use to which this permit is applicable.

Fee: $100 for up to 30 days for dumpsters.

OWNER NAME: TEL/EMAIL:

OWNER ADDRESS:

ZONE: VILLAGE SECTION: VILLAGE BLOCK: VILLAGE LOT(S):

COMPANY SUPPLYING DUMPSTER: TEL/EMAIL:

COMPANY'S ADDRESS:

LOCATION WHERE DUMPSTER WILL BE PLACED:

ESTIMATED START DATE: ESTIMATED END DATE:

IMPORTANT: DUMPSTERS ARE PROHIBITED FROM BEING PLACED ON ANY ROADWAYS.

, states that he/she is authorized to make this application and that all statements are true to the best of his/her knowledge and belief. (If corporation, give name of corporation and name, office, and address of its responsible officers).

I hereby apply for a permit for a dumpster to be placed on at the above listed location, | agree to strictly comply with all the terms, provisions and conditions of Chapter 128 of the Code of the Incorporated Village of East Rockaway, entitled "Dumpsters"; a Code to regulate, control and prescribe the method and manner of placement and maintenance of container, materials or scaffold in the Village of East Rockaway, Nassau County, New York.

Signature of Applicant

Date