Contact Person (Family / Relative) Contact No. ( Family/Relative ) To be completed for Application under the Company Name Name of Applicant / Owner
Company Registration No. Contact No. ( Office ) Contact No. ( Fax ) Contact No. (H/Phone) E-Mail Address
2.7
Contact Person
2.8
The information below is related to the premise where the water supply is provided. Premise / Unit No.
( Please state house / unit no. if apartment / condominium )
Lot No.
(Please state lot no. if applicable )
Name of Premise
( Please state name of premise / apartment / condominium if applicable )
3.5
Road / Street
Garden Section Kampung Area Postcode Postcode Area State Mailing Address
4.
5.
Declaration by Applicant / Owner I / We hereby acknowledge that the information provided above is correct. I / We hereby acknowledge to have read, understood and accepted all the terms and conditions in the Water Supply Agreement as stated in SYA/T1/1* SYA/T2/1* SYA/T3/1* (tick where appropriate) attached. I / We agree to pay for the
charges incurred by us for the supply and use of water at the premise stated above. I / We agree that in the event we fail to pay and settle any bills and charges incurred by us, SYABAS has the right to disconnect the water supply to the above premise.
_______________________________ ____ Signed by Owner / Authorised Signature FOR OFFICE USE ONLY Old Account No New Account No
_________________________ __ Date
*DOCUMENTS PROVIDED: Copy of NRIC Letter of Guarantee from Government Agencies OR Semi-Government Agencies
( Strictly for Application by Tenant for Government Agencies and Semi-Government Agencies ONLY)
6.
Please fill item a or b ( Please tick ) a. For Housing Scheme Application Quote the internal plumbing approval letter reference no. and approved internal plumbing drawings no. _______________________________________________ b. For Individual Building / Construction Supply Application Sketch internal plumbing system * (if no plan approval) or quote the internal plumbing drawings no. _______________________________________________
* sketch is to be provided in an attachment
Description Saddle Communication Pipe Service Pipe Distribution Pipe Storage Tank Pumping Main Sink Basin Water Closet Shower Urinal Water Heater Long Bath Suction Tank Electric Pump Constant Flow Valve
Type
Size mm mm mm mm litres mm
Quantity m m m m no m no no no no no no no litres /s /s no no no
Notes: All materials used must comply to as per SYABAS approved list of suppliers.
( Continuation of No.6 ) I / We wish to apply to install the supply system as stated above and we would like to appoint a plumber as stated below. The appointed plumber contractor will represent me / us in managing the said works.
___________________________ ___
____________________________________ ____
I / We agree to carry out this works without involving tapping to SYABAS pipeline. I am licensed to carry out tapping works and will manage all related works including tapping of SYABAS pipeline.
________________________ Date
7.
Declaration Agreement by Landowner where the Laying of the Water Pipes is on the Land of the Landowner I / We owner of the land with Grant No. our land. NRIC No. have no
objection to the laying of the water pipes by the above applicant or his appointed contractor / plumber on my /
__________________________ ___
________________________________________ _____
Date
* any person authorised by the Landowner or by any applicable laws enforced in Malaysia.
File No. Inspection Date Inspection Report IP3 & IP4 Recommendation Connection Cost Paid (Tapping Works) Scope of Work Extension Pipe Ferrule Saddle Premix Road Cutting Extension TOTAL (RM) Size (mm) / Yes Satisfactory Yes Quantity m no no m2 / (dd / mm / yy) No Unsatisfactory No Rate Price
Resurfacing of Road Order No. Inspection Date Scope of Work Extension Pipe Ferrule Saddle Premix Road Cutting Extension TOTAL (RM) Size (mm) / / Quantity m no no m2 (dd / mm / yy) Rate Price
___________________________ Date
___________________________ Date