Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 7
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117. Certification to Furnish Water (this section must be completed)
The
has agreed to furnish
City, Town, Village, Water Company or Water Authority
water to the area in which water main extensions are proposed by
Name the person representing the funding entity of the construction project (e.g., developer)
according to plans titled "
" and prepared by
. The undersigned acknowledges the public
Name of Engineering Firm
water supplier's responsibility for examining the plans and specifications to determine that the proposed extensions meet local rules or laws,
regulations and ordinances.
Date signed (month, day, year)
By: (signature of Public Water System official)
Title
Name of Public Water System
Page 3
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