Hc04 House Connection Proposal Form Page 2
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25. SEWER INFORMATION:
PUBLIC
a. There (is) (is not) a sanitary sewer fronting the property available for connections.
SIZE ______________
b. There (is) (is not) a storm sewer fronting the property available for connections.
SIZE ______________
c. There (is) (is not) a combined sewer fronting the property available for
SIZE ______________
connections.
d. Sanitary discharge tributary to:
Location
City Treatment Plant -
___________________________________________________________
e. Distance to, and location of nearest allowable drainage plan sewer:
i.
Sanitary Outlet _____________________________________________________________
ii. Storm Outlet _______________________________________________________________
iii. Combined Outlet ___________________________________________________________
6. WATERCOURSE INFORMATION:
There (is) (is not) a watercourse traversing the development site.
Topo. Map No.________________
Statements and Signatures (
)
Complete the appropriate sections and sign below. All professionals must affix their seal
APPLICANT
IDENTIFICATION OF RESPONSIBILITIES
I hereby state that the above information is correct and complete to the best of my knowledge and is in compliance with all
applicable Administrative Code Provisions and all Departmental Rules, Regulations, and Directives, except where noted.
Falsification of any statement is a misdemeanor under section 26-124 of the Administrative Code and is punishable by a fine or
imprisonment, or both.
It is unlawful to give to a city employee, or for a city employee to accept, any benefit, monetary or otherwise, either as a gratuity
for properly performing the job or in exchange for consideration. Violation is punishable by imprisonment or fine, or both.
Name of Applicant
Phone Number
P.E. or R.A.
Address
City
State
Zip Code
Original Seal
Signature
Date
OWNER
I hereby state that I have authorized the applicant to perform the work specified herein, and agree to indemnify and save
harmless to the fullest extent permitted by law, the City of New York, the New York City Water Board, and the New York
City Municipal Water Finance Authority (hereinafter collectively called “the City”) and their, respective officers,
representatives, agencies, contractors, servants and employees from and against any and all claims, suits, actions,
proceedings, and losses (“claims and losses”) that may arise from the construction, maintenance, operation, or use of any
connection to the City Sewer System that I or my contractor connect to the City Sewer System from the subject site after the
date of this certification and prior to the issuance of this certification and prior to the issuance of the certificate of inspection
by the City Department of Environmental Protection.
Name of Owner
Phone Number
Address
City
State
Zip Code
Signature
Date
2
safety service integrity
HC04 (10/06)
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