SNEW: South Norwalk Electric and Water > Forms > Utility Asset Information Request Form

Utility Asset Information Request Form

Date Requested (mm/dd/yyyy)

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Client Organization/Third Party to Receive Information(Required)

Location Description(Required)

(street address, latitude/longitude, SNEW pole #, intersection, feature name, boundary features, etc.)

Purpose of Request/Project Description(Required)

Buffer radius to include on map(Required)

(in feet)

Labels or other info needed

Disclaimer(Required)

The information is provided on an "as-is" basis, and South Norwalk Electric & Water makes no warranty as to the content, accuracy, or completeness of any data. Although SNEW believes the information provided to be accurate, SNEW assumes no liability for any errors, omissions, or inaccuracies in the information provided, nor assumes any liability or responsibility to any loss, injury or damage caused in connection with or arising from the information contained on the data, maps, reports, or other information provided. In no event shall South Norwalk Electric & Water become liable to the users of these data, a client organization or any other party, for any loss or direct, indirect, special, incidental or consequential damages, including but not limited to time, money or goodwill, arising from the use or modification of the data. To assist in the maintenance of the data, errors or omissions should be reported to the GIS coordinator at the address shown above.

This information is being provided to you with the understanding that the recipient shall not copy, reproduce, transfer or make any other form of or derivative work from, the product(s) provided to you for sale or other distribution, to any other person or organization other than an approved organization indicated on this form above. By receiving this information, SNEW is providing you with a limited, nonexclusive license for the information described above.

The user of this information acknowledges unconditional acceptance of the above disclaimer.

Electronic Signature (Full Name)(Required)