Form Center

2. 
3. City of Laconia, NH
   Dept. of Public Works
4. NOTE THAT QUESTIONS FOLLOWED BY AN ASTERISK * REQUIRE AN ANSWER IN ORDER TO SUBMIT YOUR APPLICATION
6. Today's Date
   Today's Date
8. Property Owner Name *
10. Mailing Street Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Email Address*
19. Property Street address
    (if different than mailing street address)
21. I, being owner of the estate above, hereby apply for a permit to connect water or cellar drain with the surface water sewer located in
23. and should such permit be granted and drain constructed, 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 surface water sewer, the street commisioner or the City of Laconia, NH.
25. I, furthermore agree to conform to all rules and ordinances of the City of Laconia, that are now or may hereafter be in force covering the excavations in streets or the construction of drains.
27. 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.
29. Electronic Signature*
31. Witness
33. Permit Number
34. Attach a Sketch here *
    Include landmarks (such as building corners) and distances
Leave This Blank:


36. Submit

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