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Revised 2019-06-26 Form 1 of 4 WATER & SEWER PERMIT APPLICATION CHECKLIST The following checklist has been made available to ensure that the permits submitted to the Water Department are reviewed in a timely manner. If the sketch submitted does not have enough information (see Form 4 below), the application will not be approved. ☐ Water/Sewer Permit Completely Filled Out Form 2 - Permit Application ☐ Property Owner’s Name & Phone Number ☐ Applicant’s Name, Address, & Phone Number ☐ Contractor’s Name, Address, & Phone Number ☐ Location of Work ☐ Purpose of Work Form 4 – Water & Sewer Service Permit Sketch (OR Attach Design Engineer’s Plans) ☐ Location (Street Address) ☐ Location of Utilities ☐ Describe Type of Work (Diameter, Material, Length, etc) ☐ Show Location of Site Features (Buildings, Driveways, Manholes, etc) ☐ Describe Backfill Operations (Compaction Method) ☐ Original Bonds – Must be on City of Albany Form ☐ Notarized ☐ Raised Stamp/Seal ☐ Liability Insurance ☐ Worker’s Compensation Insurance (If Applicable) ☐ Payment (Check or Credit Card ONLY) – See Rate Sheet for Fees ☐ Call DIG SAFE NY 72 Hours in Advance **Water and Sewer Permit Approval Must Be In Hand Before Work Starts** Permit No. KATHY M. SHEEHAN CITY OF ALBANY DEPARTMENT OF WATER & WATER SUPPLY 10 NORTH ENTERPRISE DRIVE ALBANY, NEW YORK 12204 TELEPHONE (518) 434-5300 FAX (518) 434-5332 JOSEPH E. COFFEY, JR, P.E. MAYOR COMMISSIONER ---PAGE BREAK--- Revised Aug 2020 Form 2 of 4 (Page 1) WATER AND SEWER SERVICE PERMIT APPLICATION Property Information: (Complete all sections) Service Address: Application Date: Property Owner’s Name: Property Owner’s Applicant’s Name: Applicant’s Applicant’s Applicant’s E‐Mail: General Information: (Complete all sections) Repairing broken sewer lateral? ☐YES – contaminated spoils must be removed from site ☐NO Installing backwater valve (BWV) through grant program? ☐YES – (BWV Grants needs prior approval) ☐NO Is BWV being installed inside building? ☐YES – (Plumbing Permit is required from Codes) ☐NO Terminating water or sewer connections to a building Codes required to be demolished? ☐YES ☐NO City Approved Projects: (Complete all sections) Drawing or Sketch on Form 4 is required for all projects Are water and/or sewage facilities to be turned over to AWB upon completion of Construction? ☐Yes ☐No ☐ N/A Are Stamped & Approved Plans by Department of Planning Attached? ☐Yes ☐No ☐ N/A (If N/A sketch required) ROW and Street Opening Permits: (Complete all sections) Will work occur in ROW, sidewalk, or street? ☐ YES – STREET OPENING PERMIT IS REQUIRED ☐NO Will work occur at the water or sewer main in the lawn? ☐ YES – STREET OPENING PERMIT IS REQUIRED ☐NO Street Opening Permit is obtain through DGS attention Gary Bohl 518‐462‐3519 [EMAIL REDACTED] KATHY M. SHEEHAN CITY OF ALBANY DEPARTMENT OF WATER & WATER SUPPLY 10 NORTH ENTERPRISE DRIVE ALBANY, NEW YORK 12204 TELEPHONE (518) 434-5300 FAX (518) 434-5332 JOSEPH E. COFFEY, JR, P.E. MAYOR COMMISSIONER Permit No. ---PAGE BREAK--- Revised Aug 2020 Form 2 of 4 (Page 2) Water Service: (Check at least 1 in each column) Proposed Start/End Dates: ☐ Residential ☐ New Service Connection ☐ Domestic ☐ Commercial ☐ Service Rehab Size & Work Type ☐ Fire Protection ☐ Industrial ☐ Termination (must be at main) Replacing lead water service to copper? ☐YES – Schedule a Tap 48 hours in advance with Dispatch ☐NO Description/purpose of work: Is Contractor the same as Applicant? ☐YES (skip to next section) ☐NO – FILL OUT BELOW Contractor’s Name: Phone: Contractor’s Address: Email: Sewer Service: (Check at least 1 in each column) Proposed Start/End Dates: ☐ Residential ☐ New Service Connection ☐ Sanitary Sewer ☐ Commercial ☐ Service Rehab Size & Work Type ☐ Storm Service ☐ Industrial ☐ Termination (must be at main) Description/purpose of work: Is Contractor the same as Applicant? ☐Yes (skip to next section) ☐No – FILL OUT BELOW Contractor’s Name: Phone: Contractor’s Address: Email: To the best of my knowledge the above information is true and accurate. I have read and understand the provisions of the Code of the City of Albany concerning use of its water and sewer systems and shall comply with said Code. I will be responsible for excavation, removal, and backfill as required to restore to City specifications/requirements guaranteeing this work for five years. I acknowledge all permit applications must undergo a 2‐5 day business review once a complete application is submitted. Permit fees and unpaid balances with the Albany Water Department must be paid prior to issuance of a permit. Applicant’s Signature: Date: Please Print Name: SIGN ---PAGE BREAK--- Revised Aug 2020 Form 3 of 4 WATER AND SEWER SERVICE PERMIT APPLICATION MAINTENANCE DIVISION Size of Water Main to be Tapped Size of Tap Installed Size of Sewer Main to be Connected Size of Service Installed METERING DIVISION – Meter Superintendent Call Meter Superintendent, John Tedesco, at 518‐209‐4284 to schedule hydrant meters. FINANCE DIVISION Bond ☐Yes ☐No Date Expires Insurance ☐Yes ☐No Date Expires Workers Comp. ☐Yes ☐No ☐N/A Date Expires Water Service Charges Sewer Service Charges Total Water / Sewer Charges Application Fee Sanitary App Fee Water Service Charge Tapping Fee New Sanitary Connection Fee Sewer Service Charge Meter Fee Other Total Permit Charge New Service Connection Fee Storm App Fee Amount Paid Hydrant Fee Other New Storm Connection Fee Check # Credit Card Type Total Water Total Sewer ---PAGE BREAK--- ---PAGE BREAK---