Permit Application Form - City Of Pittsfield Department Of Public Works And Utilities
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1CITY OF PITTSFIELD
DEPARTMENT OF PUBLIC WORKS AND UTILITIES
__________________
APPLICATION FOR PERMIT
________________
(NOT TO BE CONSTRUED AS AN APPROVAL)
(DATE)
TO THE COMMISSIONER, CITY HALL, PITTSFIELD, MA 01201:
STREET ADDRESS__________________________________________________MAP/BLOCK/LOT: ______________________
I, THE UNDERSIGNED ____________________________________________________________________________________
NAME
TELEPHONE
__________________________________________________________________________________________________________
MAILING ADDRESS
OWNER,OR ACTING AS THE LEGAL AGENT FOR
________________________________________________________________________
NAME
TELEPHONE
______________________________________________________________________
ADDRESS
IN CONSIDERATION OF A DEPOSIT OF $_________________ DO HEREBY APPLY FOR A PERMIT TO:
1. (
) CONNECT TO THE WATER MAIN IN __________________________________
USING A _________ -INCH
___________________PIPE.
2. (
) CONNECT TO THE SEWER MAIN IN __________________________________
USING A _________ -INCH
___________________ PIPE.
3. (
) CONNECT TO THE STORM DRAIN IN _________________________________
USING A _________ -INCH
___________________ PIPE.
4. (
) REPAIR AN EXISTING (WATER) (SEWER) (DRAIN) SERVICE USING A __________ -INCH ________________________PIPE.
EMERGENCY: NO_____YES_____ (IF YES) DIGSAFE NUMBER _______________________________________
5. (
) INSTALL A SENSUS RADIO READ WATER METER (NOTE: METER MUST READ IN CUBIC FEET) SIZE: ____________________________
6. (
) INSTALL CROSS-CONNECTION DEVICE (PROVIDE AN 8 ½ X 11 DATA DESIGN SCHEMATIC -INCLUDING MAKE , SIZE & TYPE)
7. (
) KILL OR DISCONTINUE (WATER) (SEWER) (DRAIN) SERVICE TO: _________________________________________________________________
8. (
) CONNECT TO THE STREET WITH _____________ -FOOT WIDE DRIVEWAY
(ATTACH SKETCH SHOWING ALL ABOVEGROUND OBJECTS WITHIN 50 FEET OF DRIVEWAY.)
9. (
) EXCAVATE IN CITY RIGHT-OF-WAY OR ACCEPTED STREET FOR: WATER _____SEWER _____DRAIN _____DRIVEWAY ____ OTHER _____
10.(
) OCCUPY PUBLIC (STREET) (SIDEWALK )(RIGHT OF WAY) FOR: 10 DAYS OR LESS_______10 TO 30 DAYS_______OVERSIZE LOAD _______
11.(
) OTHER _______________________________________________________________________________________________________________________
MY CONTRACTOR OR PLUMBER WILL BE: ______________________________________________________________________________________________
NAME
MAILING ADDRESS
TELEPHONE
ANY EXCAVATION WILL BE DONE BY: _________________________________________________________________________________________________
NAME
MAILING ADDRESS
TELEPHONE
IN CONSIDERATION OF ISSUANCE OF SUCH A PERMIT, I HEREBY AGREE TO COMPLY WITH AND CONFORM TO ALL LAWS, RULES
ORDINANCES,
GENERAL CONDITIONS OF PERMITS, REGULATIONS AND POLICIES OF THE CITY, STATE OR FEDERAL GOVERNMENT
CONCERNING THE CONSTRUCTION AND PROPER MAINTENANCE AND OPERATION OF WATER, SEWER, DRAIN, STREET, AND SIDEWALK
FACILITIES AS MAY APPLY. I FURTHER AGREE TO HOLD HARMLESS THE SAID CITY OF PITTSFIELD AND ITS AGENTS FROM ANY AND ALL
LOSS, COST, DAMAGE, OR EXPENSES IN CONNECTION WITH OR CONSEQUENT UPON THE PERFORMANCE OF SAID WORK AND TO WAIVE ALL
CLAIMS FOR DAMAGE IN CASE OF REVOCATION OF ANY PERMIT ISSUED PURSUANT TO THIS APPLICATION. SEE "GENERAL CONDITIONS OF
PERMITS" ON BACK OF THIS APPLICATION.
THIS IS NOT A PERMIT
NO WORK IS TO BE PERFORMED UNTIL A PERMIT IS RECEIVED
_________________________________________________________________
DATE:______________________________
(SIGNATURE)
1.$100 (w/Tap $400) 2. $100 3. $100 4. $100 5. N/C 6. $60 7. $100 8. $25 9. $25 10.15/$25/$50
FEES PER EACH CHECKED:
(Local $100/yr)
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