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Narrowsburg Water
District
PO Box 195, 210 Bridge Street
Narrowsburg, NY 12764
(845)252-7376 / 7146
APPLICATION FOR WATER / SERVICE REPLACEMENT
ITEMS TO BE INCLUDED WITH THE APPLICATION:
1. APPLICATION FEE: RESIDENTIAL/TWO
FAMILY - $75.00
COMMERCIAL/MULTI-FAMILY - $150.00
2. SITE PLAN
3. FLOOR PLAN
DATE__________________
APPLICANT
NAME_________________________________________________________
ADDRESS______________________________________________________________________
TELEPHONE____________________
TAX MAP SECTION______BLOCK______LOT______
BUILDING/DWELLING
USE________________________________________________________
INSTALLING CONTRACTOR:
NAME_________________________________________________________________________
ADDRESS______________________________________________________________________
TELEPHONE_____________________________
OWNER:
PROPERTY
OWNER__________________________________________________
PROPERTY
ADDRESS______________________
TELEPHONE_____________________________
TYPE OF SERVICE:
SINGLE FAMILY____ TWO-FAMILY ____
MULTI-FAMILY____
COMMERCIAL____ SPRINKLER SYSTEM____ SERVICE LINE REPLACEMENT_____
BUILDING ADDITION____ OTHER_______________
INDICATE BELOW OR ATTACH A PLAN OR SKETCH OF THE PROPOSED
BUILDING, WATER SERVICE AND FOUNDATION ENTRY SHOWING THE LENGTH OF
SERVICE, SIZE OF SERVICE, ETC.
THE UNDERSIGNED, AS OWNER OF THE PROPERTY/BUILDING TO BE CONNECTED
TO THE MAINS OF THE NARROWSBURG WATER DISTRICT AGREES
TO ABIDE BY APPROVED CONSTRUCTION PRACTICE SUBJECT TO THE APPROVAL
OF THE OFFICIALS OF THE TOWN OF TUSTEN AND ALL APPLICABLE RULES,
REGULATIONS AND ORDINANCES GOVERNING THE CONNECTION DESCRIBED,
INCLUDING ALL AMENDMENTS THERETO. I AFFIRM UNDER PENALTY OF
PERJURY THAT ALL INFORMATION ABOVE AND ATTACHED IS CORRECT TO THE
BEST OF MY KNOWLEDGE AND BELIEF.
OWNER
SIGNATURE_____________________ DATE__________________________
CONTRACTOR
SIGNATURE_____________________ DATE__________________________
The Narrowburg Water and Sewer
Districts prohibit discrimination on the basis of race, color,
national origin, sex, religion, age, disability, political
beliefs, marital or familial status. Complaints of discrimination
may be filed with the Tusten Town Supervisor at 210 bridge Street,
Narrowsburg NY 12764 or by calling (914)252-7146.The Narrowburg
Water and Sewer Districts are equal employment opportunity
employers.
Approved by Tusten Town Board
4/9/01. |
