SYARIKAT BEKALAN AIR SELANGOR SDN BHD (393257-T) APPLICATION FORM FOR WATER SUPPLY – TARIFF CODE 10 (FOR DOMESTIC CONSUMPTION)

1. To be completed for – Application under the name of Individual

1.1 Name of Applicant / Owner(As per NRIC / Passport)

1.2 NRIC of Applicant / Owner:

(a) New

(b) Old

(c) Army / Police

1.3 Passport No.(Non-Malaysian Citizen)

1.4 Contact No. (Office)

1.5 Contact No. (House)

1.6 Contact No. (Fax)

1.7 Contact No. (H/Phone)

1.8 E-Mail Address

1.9 Contact Person (Family / Relative)

1.10 Contact No. ( Family/Relative )

2. To be completed for – Application under the Company Name

2.1 Name of Applicant / Owner

2.2 Company Registration No.

2.3 Contact No. ( Office )

2.4 Contact No. ( Fax )

2.5 Contact No. (H/Phone)

2.6 E-Mail Address

2.7 Contact Person

2.8 Contact No. of Contact Person

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SYA/F1A/A2

3. The information below is related to the premise where the water supply is provided.

3.1 Premise / Unit No.( Please state house / unit no. if apartment / condominium )

3.2 Block / Floor No.( Please state block / floor no. if applicable )

3.3 Lot No.(Please state lot no. if applicable )

3.4 Name of Premise

( Please state name of premise / apartment / condominium if applicable )

3.5 Road / Street

3.6 Garden

3.7 Section

3.8 Kampung

3.9 Area

3.10

Postcode

3.11 Postcode Area

3.12

State

3.13

Mailing Address

4. Type of Account ( Please tick “√” )

New Account Change of Name

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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

___________________________

Date

___________________________________

Stamp of Organisation* (* for non-individuals)

FOR OFFICE USE ONLY

Old Account No Tariff Code

New Account No Route No./Book

Deposit (RM)

*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)

Copy of Title Sketch of internal plumbing system

Copy of Sale & Purchase Agreement Copy of Company Registration Certificate

Others; Please specify, ___________________________________________________________________________________________

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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

SCOPE OF WORK ( To be filled up by the Plumber) where item “b” is ticked.

Description Type Size Quantity

Saddle mm m

Communication Pipe mm m

Service Pipe mm m

Distribution Pipe mm m

Storage Tank litres no

Pumping Main mm m

Sink no

Basin no

Water Closet no

Shower no

Urinal no

Water Heater no

Long Bath no

Suction Tank litres no

Electric Pump ℓ/s no

Constant Flow Valve ℓ/s no

Notes: All materials used must comply to as per SYABAS approved list of suppliers.

________________________

Date

_______________________________________

Plumber Licence No.

___________________________________

Signature of PlumberName:

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( 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.

______________________________

Date

________________________________________

Signed by Owner / Authorised Person

Name of Plumber

License No.

Type of Licence

Expiry Date / / ( dd / mm / yy )

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

____________________________________

Plumber Licence No.

___________________________________

Signature of PlumberName:

7. Declaration Agreement by Landowner where the Laying of the Water Pipes is on the Land of the Landowner

I / We NRIC No.

owner of the land with Grant No. have no objection to the laying of the water pipes by the above applicant or his appointed contractor / plumber on my / our land.

_____________________________

Date

_____________________________________________

Signature by Landowner / Authorised Person*

* any person authorised by the Landowner or by any applicable laws enforced in Malaysia.

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FOR OFFICE ONLY

File No.

Inspection Date / / (dd / mm / yy)

Inspection Report IP3 & IP4 Yes No

Recommendation Satisfactory Unsatisfactory

Connection Cost Paid (Tapping Works) Yes No

Scope of Work Size (mm) Quantity Rate Price

Extension Pipe m

Ferrule no

Saddle no

Premix Road Cutting m2

Extension

TOTAL (RM)

Sketch of General Pipe (To be filled up by the Technician)

FOR OFFICE USE ONLY

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Resurfacing of RoadOrder No.

Inspection Date / / (dd / mm / yy)

Scope of Work Size (mm) Quantity Rate Price

Extension Pipe m

Ferrule no

Saddle no

Premix Road Cutting m2

Extension

TOTAL (RM)

Recommended / Not Recommended

________________________________________TechnicianName:

___________________________ Date

Approved / Not Approved

________________________________________Head of DistrictName:Stamp:

___________________________ Date

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