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i <br />PAY �►aREE[�NS <br />RECEIVtD <br />SEP 2 � i:�kl <br />UTILITIES DIV. <br />The underaiane3 liereby requests the City of Everett to waive <br />the PRV charge on his/her water service at <br />� G/ ,v G��i %�� Jh�? �i� _. The undarsiened <br />representa that Lhe service at said location presently has a PRV <br />in good Norking order and that, in conaideration of waiver of <br />snid charae, for the period that undersigned is a water service <br />customer at the above location, the undersigned agrees: <br />1. To maintain said PRV in good working order; arid <br />� <br />2. To release the City of Everett from any and all <br />liability arisinB Prom increasad operating pre=sures on � <br />the �t5 transmission line to which the above water <br />service is connected; and <br />3. To indemnify and hold harmless the C1ty of Everett from <br />any and all claims related to the failure of the PRV <br />installed at the above location. This indemnity is on <br />behalf oP the undersigned, and the underai6ned agrees <br />to notity the city of Everett of any chanee of <br />oitnership of the water service connection at the abo� <br />location. <br />DATED this � day of <br />STATfi OF WASH,LNGTON) <br />ss: <br />COUNTY OF �) <br />I certiPy that I know or have satisfactory <br />evidence <br />that �� � ? n -�� ^'��'`Q�'� signed this <br />instrument and acknowledged it to be (his, her, Lheir) free <br />and voluntary act for <br />instrument. <br />(Seal or Stemp( <br />tha uses and purposes mention in Lhe <br />Dated: ��t�_�P�------- <br />SiBnature of <br />Notary Public: ' � — -- <br />Title: � <br />My commission expires:�r��L�.�9i6 <br />