Application for a Sewer Connection Permit

2. 

3. City of Laconia
   Dept. of Public Works

   Dept. of Public Works

4. NOTE THAT QUESTIONS FOLLOWED BY AN ASTERISK * REQUIRE AN ANSWER IN ORDER TO SUBMIT YOUR APPLICATION

   NOTE THAT QUESTIONS FOLLOWED BY AN ASTERISK * REQUIRE AN ANSWER IN ORDER TO SUBMIT YOUR APPLICATION

6. Property Owner Name*

7. Date*
   Date

9. Mailing Address

11. City

12. State

13. Zip Code

15. Phone Number*

16. Email Address*

18. Work Site Street Address*

    (if different than Mailing Address)

22. Contractor Name*

    (the person responsible to connect with the sewer)

23. Company

25. Mailing Address

27. City

28. State

29. Zip Code

31. Phone Number*

32. Email Address*

36. Plumber Name

    (if different than contractor)

38. Phone Number

39. Email Address

43. I wish to connect with the public sewer a

    building type: residence, motel, laundromat, trailer, . . .

45. containing the following fixtures:
    (Type in the number of each type of fixture. If you skip an answer, it is considered zero.)

    (Type in the number of each type of fixture. If you skip an answer, it is considered zero.)

46. Bath Group

48. Water Closets

49. Lavatories

50. Automatic Washers

52. Bath Tubs

53. Sinks

54. Dish Washers

56. Urinal

57. Showers

58. Garbage Disposal

60. I agree for myself, my heirs and assigns, to hold and save harmless, from any loss, cost damage or expense, happening by reason of any defect or blockage of said sanitary sewer, the street commissioner or the City of Laconia, NH.

61. Attach a picture of a hand-drawn sketch here

    Include landmarks and distances.

63. I further agree not to discharge into the sanitary sewer any surface water, cellar water or water from rain conductors as decreed by City Ordinance.

65. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
67. Contractor Electronic Signature

69. Your application cannot be approved until we receive payment in full. A permit costs $330, unless you are a first time user. A permit for a first time user costs $1,130. We cannot accept credit card payment online or over the phone at this time. Checks (written to the "City of Laconia") can be placed into the drop box at the south entrance of the DPW building during business hours (Mon-Fri 7:30am-4:00pm) or can be mailed to Laconia Department of Public Works, 27 Bisson Ave., Laconia, NH 03246.

    Your application cannot be approved until we receive payment in full. A permit costs $330, unless you are a first time user. A permit for a first time user costs $1,130. We cannot accept credit card payment online or over the phone at this time. Checks (written to the "City of Laconia") can be placed into the drop box at the south entrance of the DPW building during business hours (Mon-Fri 7:30am-4:00pm) or can be mailed to Laconia Department of Public Works, 27 Bisson Ave., Laconia, NH 03246.

73. Date of Permit Issue

74. Approved by

75. Permit Number

77. Date of Inspection

78. Inspection by

Leave This Blank:


80. Submit

* indicates a required field