FORM RA1 Refer Chapter IV (A) Para 1

KERALA WATER AUTHORITY

APPLICATION FOR PERMANENT/CASUAL/NEW WATER CONNECTION 1. 2. 3. Name Address House No. : : :

4. a) b) c)

Details of Licensed Plumber for Internal Pipe laying Name Address Licence No. : : :

Consumer Category:

DOMESTIC / NON DOMESTIC / INDUSTRIAL / PANCHAYAT / MUNICIPALITY / CORPORATION

6. 7.

Division Sub-Division : Other Particulars :

I hereby agree to the rules and conditions of Authority for connection.

Date: APPROVAL OF LOCAL BODY

Signature

Above application may be considered Subject to..

Date: INTIMATION TO THE APPLICANT

Signature/Seal of Local Body

Kindly pay estimate fee of Rs. this application to the undersigned along with receipt to the Cashier and submit

Date : For Office Use Only 1. 2. 3. Estimate Fee : Estimated Deposit Special Deposit Receipt No Rs Receipt No Rs Receipt No Rs Receipt No

Assistant Executive Engineer

dt dt dt Other Payments Rs

dt

KERALA WATER AUTHORITY

Form No. RA 1 a

Application for Water Connection

(Not transferable) Note: 1. Please do not leave any column unattended. 2. Please use CAPITAL letters for filling this page. Sub Division Section Area

Division

Name of Applicant

Address for communication Address of premises to which connection is required Building No House Name Street/Lane: Post Office Pin Code Survey No. Near House No Near KWA Consumer No. Telephone No. (if any)

4.

Category of connection required Domestic Single dwelling unit Multi dwelling units Govt. School Govt. Hospital Others (specify)

No. of units : No. of students : No. of beds :

2.

Non Domestic Office Hall, Mandapam Hostel Private School Shop Restaurant Hotel & Lodging Colleges Hospital/Clinic P.C. Station Temple Church Mosque Park/Garden Capacity No. of occupants No. of students No. of staff No. of seats No. of beds No. of students No. of beds No. of Toilet

3. Industrial Special Casual Others (specify) Specify the industry Construction Exhibition/Fairs etc.

5.

Quantity of water required per day 1. Expected quantity required / day :

2. If alternate source available, give details :

6.

Building Details 1. 2. Building Permit No. & date : Plinth area :

7.

Present stage of construction Not started Partially completed : : : Completed Occupied

1. 2. 3.

If partially completed, present stage Present source of water, if any No. of occupants (present/excepted)

Details of plumbing Works

1. Inside installation done or not : 2. Approval No. & date if done 3. Size of connection required 4. No. of taps 5. No. of flushing cisterns 6. No. of other taping points 7. Total outlets : : : : : :

9.

Water connection is to a sump or not If yes, give the details, 1. Size (LxBxH)/Capacity 2. Material of construction : :

3. Water tightness test conducted or not : 4. Details of pumping system :

10

Details of previous connections at site, if any

11. Whether the applicant is an existing consumer of Kerala Water Authority : If yes, give the details, 1. Consumer Number/s 2. Section 3. Subdivision 12 List of enclosures 1. OwnershipCertificate from the Local Body (Obtained with in 3 months of date of Application) 2 3 Plumbing plan - 3 copies attach additional copies if road/Berm cutting is necessary) Necessary postage stamps for the acknowledgment card, road cut card, provisional approval card 13 1. 2. 3. : : :

Declaration of the applicant

I hereby undertake that all the details given above are true to the best of my knowledge and belief I hereby authorize M/s to execute the Plumbing work. I have read/understood the relevant clause? The Kerala Water Authority (Water Supply)

Regulation, 1991 and hereby agree to abide by the same.

Dated Signature of the Applicant

14.

Details of Plumber 1. Name 2. Name of firm 3. Address

: : :

4.

License No.

15.

Declaration of the Plumber

1. I hereby declare that I have personally inspected the premises to which the water connection is applied for and the details given above are correct to the best of my knowledge. 2. I hereby declare to undertake and complete the work as per the rules of the K.W.A. 3. All the inside installation will be/has been done as per the water supply rules. 4. I have personally conducted and satisfied the water tightness test of the sump.

(Seal)

Dated Signature of the Plumber

For Office Use

Sub Division / Section Office Register No. :

1. 2.

Date of receipt of application Verification certificate of application

Dated Signature of D/man

Forwarded to the Assistant Engineer,.......... Section on. for site inspection, feasibility report and remarks.

Dated Signature of Assistant Executive Engineer 11 Section Office 1. Forwarded to W.W.l./Overseer,. On ..

Dated Signature of Assistant Engineer

2. Report of W. W.L/Overseer

Dated Signature of W.W.L/Overseer 3. Feasibility report and recommendations of the Assistant Engineer

Dated Signature of Assistant Engineer Details of amount to be remitted a. Deposit amount Connection Fee : b. Street main extension charges : c. Inside Fee : : : : : :

d. Extension Fee e. Centage charges f. Others (specify)

g. Fines (specify) Total Amount

Submitted to the Assistant Executive Engineer on

Dated Signature of Assistant Engineer III Sub Division Office 1 The request for the sanction of cutting is sent to the on.

Dated Signature of Assistant Executive Engineer 2 Date of receipt of the sanction for road cutting at the sub division is on.

Dated Signature of D/man

Provisional Approval of the connection 1 Kindly pay an amount of Rs. (Rsonly) to the Sub Division towards the water supply connection. 2 3 You are requested to produce a sound water meter with test certificate. You are requested to execute the water supply agreement with the undersigned on any working day after the remittance of the above amount. 4 If you fail to comply with the above within three months, this approval / sanction for water connection shall be considered as cancelled. Dated Signature of Assistant Executive Engineer 4 Intimation to the applicant Intimation to the applicant sent on Dated Signature of D/man 5 Collection of amount at the sub division and allotment of consumer No. 1 2 3 4 5 6 7 5 Receipt Nos. and date Amount Consumer No.allotted Category of connection PIC assigned, KL/month PIC amount/month Work order No. : : : : : : : Dated Signature of Cashier/J.S. of Sub Division Issue of Work Order Work order issued and transmitted to the Assistant Engineer on .. Dated Signature of Assistant Executive Engineer IV Section Office 1 Date of receipt of completion report 2 3 1 Priority No. Date of connection

: : :

Dated Signature of Assistant Engineer Remarks of W.W.I./Overseer Connection given on. and the provisional invoice and meter reading card issued to the consumer. Dated Signature of W.W.L/Overseer

Remarks of the Assistant Engineer Dated Signature of Assistant Executive Engineer