Application for Permit for Tap, Plug, Wet …

1 The City of New York Department of Environmental Protection Application for Permit for Tap, Plug, Wet connection , repair /Relay of Water Service Line Please Print Applicant must be a Licensed Plumber Work Site Street Address: _____ Borough: _____ Block: _____ Lot(s): _____ City, State, Zip Code: _____ Tentative Lot(s): _____ Check One: ____ Tap ____ Wet connection ____ Plug ____ repair /Relay Service Line ____ Tap and Plug ____ Wet connection and Plug Name of Street on which Tap/Wet connection is to be Installed _____ (Circle One) (ST) (AVE) (RD) (DR) (OTHER) Tap or Wet connection to be Installed on North South East West side of the street.

2 (Circle One) Size of other City/ Size of City Water Main _____ Detail Distribution Map No. _____ Private Water Main(s) _____ Size of Private Water Main _____ Type of Service Domestic Fire Sprinkler Standpipe Combined (Circle One) Size of Internal Water Main _____ Approx. Length of Service _____ Tap/Wet connection Size _____ Plug(s) (how many?) _____ Service Size _____ How Many Sprinkler Heads? _____ Estimated Demand (gpm) _____ DOT Highway Permit No. _____ Rated Capacity of Pumps (gpm): Domestic _____ Fire/Sprinkler: _____ DOB New Building # or Alteration # _____ Building Size: _____ Cross connection Control Approval (yes or no) _____ Schedule B attached (yes or no) _____ Is Plug in Same Excavation Cross connection Control Exemption (yes or no) _____ as existing (yes or no) _____ Describe Tap Work (Install?)

3 Plug? Relay? repair ? Locate?) /Nature of repair /Other Comments _____ _____ Other Existing Taps/Wet Connections, Service Lines and Meters for this Property: Size Size Account # or Meter # (1) (1) (1) Other Taps/Wet Connections (2) Other Service Lines (2) Other Meters (2) (3) (3) (3) (4) (4) (4) Describe the property use. Check all that apply: [ ] Industrial [ ] Retail [ ] Residential [ ] Medical/Dental [ ] Warehouse [ ] Car Wash [ ] Hospital [ ] School [ ] Office [ ] Factory [ ] Restaurant [ ] Laundry [ ] Dry Cleaner [ ] Other (specify)_____ For plugs : Size of to be Destroyed Location of to be Destroyed Meter Number corresponding to to be Destroyed Account Number Corresponding to to be Destroyed 1.

4 2. 3. 4. The undersigned plumber being the duly authorized agent for the owner of the above property, hereby agrees to destroy all existing abandoned taps supplying this or the former building slip, and in case of this failure to do so, will be suspended immediately and further permits to him refused. Plumber s Name (Print): _____ License Number: _____ Signature: _____ Plumber s CIS Account No.: _____ Business Address _____ Application Date: _____ City/State/Zip Code: _____ BWSO Approximate Date of Work: _____ Approved By: _____ Approval Date: _____ BCS Premises Account #: _____ Permit Type: _____ Number: _____ Fee: _____ Date Issued: _____ Issued by: _____ Form BWSO/BCS Revised 1/15/04