ANNEXURE VIII From ______________________
___________________________
___________________________
Dated: -
To,
Assistant Engineer,
S.D. II W.D. IX (PHE),
PWD Monte-Margoa.
Sub: - Providing water connection to the SC/ST/OBC and other weaker section peoples of the Society. Under LIG Scheme in ____________________________ constituency.
Sir,
I the undersigned hereby apply for availing the water connection under the Government Scheme mentioned in the subject above, and furnish the details below as per requirement.
Name of the Head of Family :
No. of Persons in the Family :
Relationship with head of Family :
House No. in the land :
Income / Caste certificate issued
by competent authority : enclosed
I hereby undertake that:
1. The responsibility of safe custody of water meter and installation and shall bear the necessary cost of damages/theft if any.
2. Payment towards water supply bills whenever issued will be paid by me within the due stipulated. Incase of non-payment of bill the department free to disconnect the installation.
3. Security deposit of Rs. 50/- will be deposited with the PWD by me when intimated.
4. Whether NOC from Land Owner or order from Under Health Act from Chief Officer Margao, Muncipality is attached or not
5. Whether the affidavit of any kind is enclosed or not
ANNEXURE VIII (contd.)
AFFIDAVIT CUM NOC
I the undersigned, _____________________________________________, major in age, Indian National, resident of _______________________________________________, village of ___________ Taluka, do hereby solemnly state and affirm as under:-
1. I say that I am an occupant of premises situated in the property under surveyed No. ________ situated at _____________________________________________________, village of __________ Taluka state of South-Goa.
2. I hereby declare that for releasing the water connection to my installation the pipeline will not cross any other person property. In case it does, I held myself responsible for any consequences arising there from.
3. I say that water supply Department shall be not responsible for any disputes/litigations if raises after taking Water Connection and I state that I shall pay the bills towards water supplied by the Department even in case of the irregular water supply as per the availability of water also I state that water supply Authority is free to disconnect the water connection anytime without any notice.
4. I say that I am taking this Affidavit in order to produce it to the Office of the Assistant Engineer, Sub Division WD PWD, Goa for availing Water Connection at my cost and risk.
I say that whosoever has been stated hereinabove is true to the best of my knowledge and belief and that on part of it is false.
Solemnly affirmed at _______________ on this ___________ day of __________, 2010
IDENTIFIED BY ME:-
Identity Card No.:
DEPONENT