Form Pw5 - After Hours Work Permit Application
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1PW5: After Hours
Orient and affix BIS
Work Permit Application
job number label here
Must be typewritten
All information must be completed for review of this request. Incomplete submissions will be denied without review.
The deadline to submit weekend variance requests is Tuesday at 4:00PM, and variances will not be granted for any day earlier than Saturday of the same week.
1 Initial Filing Status Information
Required for all applications. Check applicable box for application type.
Work Permit No.
BIS Job
Electrical Application
Variance Type:
Initial
Renewal
2 Location Information
Required for all applications.
House No(s)
Street Name
Borough
Block
Lot
BIN
CB No.
Work on Floor(s)
Apt/Condo No(s)
3 Contractor
Required for all applications. Business Fax and Email are optional.
Last Name
First Name
Middle Initial
Business Name
Business Telephone
Business Address
Business Fax / Email
City
State
Zip
Mobile Telephone
License Number
License Type
GC
Electrician
MP
FSC
Other:
4 Please provide main point of contact information during AHV work
Required for all applications.
Last Name
First Name
Mobile Telephone
Email
5 Variance Information
Required for all applications.
Is a residence within 200 feet of the site?
Yes
No
Is all work being done within an enclosed building?
Yes
No
Does any of the work involve full or partial demolition?
Yes
No
Does any of the work involve crane use?
Yes
No
Total Number of Days Requested:
Days of Week Date(s) Requested
Hours
Description of Work (Specify weekday vs. weekend work)
Monday
to
Tuesday
to
Weekday
Wednesday
to
Thursday
to
Friday
to
Saturday
to
Weekend
Sunday
to
Reason for Variance:
Internal Use Only
6 Statements and Signature
Required for all applications.
Approved
Denied
Limited Approval
This permit must be posted visible to the public. Falsification of any statement is a misdemeanor and is
punishable by a fine or imprisonment, or both. It is unlawful to give to a city employee, or for a city
Indicate days-of-week authorized for electronic renewal
employee to accept, any benefit, monetary or otherwise, either as a gratuity for properly performing the job
or in exchange for special consideration. Violation is punishable by imprisonment or fine or both.
Limited to:
I understand that if I am found after hearing to have knowingly or negligently made a false statement or
to have knowingly or negligently falsified or allowed to be falsified any certificate, form, signed
statement, application, report or certification of the correction of a violation required under the provisions
of this code or of a rule of any agency, I may be barred from filing further applications or documents with
the Department.
I hereby certify as the permittee or as a representative of the permittee that a noise mitigation plan for
the site has been developed in accordance with Administrative Code § 24-219 through § 24-224 and
that such plan is in compliance with the Department of Environmental Protection’s noise mitigation rules.
I further affirm and attest that the afterhours and/or weekend construction work defined in the work
scope of this application is submitted for the purpose and consideration indicated in section 5 of this
application, “Reason for Variance.”
Borough Commissioner Signature
Date
Contractor or Authorized Representative (print)
Signature
Date
Filing Fee
Permit Fee
05/17
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