Transcription of EMERGENCY STREET OPENING PERMIT FORM
1 Rev. 5/18/16 11. House No.:_____ 0108 INSTALL POLE___ 0127 CONDUIT CONSTRUCTION (CABLE, TELECOMM. AND FRANCHISE)___ 0113 REPAIR WATER___ 0136 DEP CONTRACTOR MAJOR INSTALLATION WATER___ 0114 REPAIR SEWER___ 0137 DEP CONTRACTOR MAJOR INSTALLATION SEWER___ 0115 REPAIR WATER/SEWER___ 0156 REPAIR TRAFFIC STREET LIGHT___ 0116 FUEL OIL LINE___ 0157 REPAIR TRAFFIC SIGNALS___ 0122 REPAIR GAS___ 0204 STEAM STACKEND DATE:___ 0123 REPAIR STEAM___ 0124 REPAIR ELEC. / COMMUNICATIONS___ 0204 NITROGEN TANKEND DATE:(Utilitites Only)# OF TANKS 14. Is heavy equipment being used?____ YES____ NO 15. Is service cut off to anyone?____ YES____ NODate:_____/_____/_____ 16. What is the Nature of the EMERGENCY ? (Describe in Detail):Recorded #Date:DOT OperatorTime: / /FOR OFFICIAL USE ONLY / /15a. If YES, When was the service cut off?Time:_____/ / SECTION D: Nature of the EMERGENCY SECTION C: Type of PERMIT Requested (Check One)/ / 12a.
2 STREET Work On, If Different From Above:_____ 13. Between:_____ and _____(Cross STREET #1)(Cross STREET #2)2. Permittee Name:_____ SECTION B: Location of EMERGENCY 10. Borough (Check One): ___ MANHATTAN ___ BROOKLYN ___ QUEENS ___ BRONX ___ STATEN ISLAND12. On STREET :_____ 8. Company Official To Certify EMERGENCY Status:9. Tel #:( ) -FAX: : 3. Address:_____ 4. Caller Name:_____5. Tel #:(_____)_____-_____ 6. Employee ID#:_____7. Time of Request:_____ SECTION A: Applicant Information 1. Permittee ID#:_____EMERGENCY STREET OPENING PERMIT FORME mergency Number (Official Use Only)DateNYC DOT CONTACT NUMBERS/ /BUSINESS HOURS (8:30am-3:25pm)NON-BUSINESS HOURS (3:30pm-8:25am)TEL.
