SYA/F1A/A2

SYARIKAT BEKALAN AIR SELANGOR SDN BHD (393257-T)

APPLICATION FORM FOR WATER SUPPLY TARIFF CODE 10 (FOR DOMESTIC CONSUMPTION) 1. 1.1 1.2 To be completed for Application under the name of Individual Name of Applicant / Owner (As per NRIC / Passport) NRIC of Applicant / Owner: (a) New (b) Old (c) Army / Police 1.3 1.4 1.5 1.6 1.7 1.8 Passport No. (Non-Malaysian Citizen) Contact No. (Office) Contact No. (House) Contact No. (Fax) Contact No. (H/Phone) E-Mail Address

1.9 1.10 2. 2.1

Contact Person (Family / Relative) Contact No. ( Family/Relative ) To be completed for Application under the Company Name Name of Applicant / Owner

2.2 2.3 2.4 2.5 2.6

Company Registration No. Contact No. ( Office ) Contact No. ( Fax ) Contact No. (H/Phone) E-Mail Address

2.7

Contact Person

2.8

Contact No. of Contact Person

3. 3.1 3.2 3.3 3.4

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 )

Block / Floor No.

( Please state block / floor no. if applicable )

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

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

3.5

Road / Street

3.6 3.7 3.8 3.9 3.1 0 3.11 3.1 2 3.1 3

Garden Section Kampung Area Postcode Postcode Area State Mailing Address

4.

Type of Account ( Please tick ) New Account Change of Name

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

________________________________ ___ Stamp of Organisation* (* for non-individuals)

Tariff Code 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 Copy of Sale & Purchase Agreement

Sketch of internal plumbing system Copy of Company Registration Certificate

Others; Please specify, ___________________________________________________________________________________________

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 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.

_____________________ ___ Date

__________________________________ _____ Plumber Licence No.

________________________________ ___ Signature of Plumber Name:

( 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 Name of Plumber

Signed by Owner / Authorised Person

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 Plumber Name:

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

Signature by Landowner / Authorised Person*

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

FOR OFFICE ONLY

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

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

FOR OFFICE USE ONLY

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

Recommended / Not Recommended

________________________________________ Technician Name: Approved / Not Approved

___________________________ Date

________________________________________ Head of District Name: Stamp:

___________________________ Date