10523 19TH PL W 2016-01-01 MF Import

MUKIC,TEO WATER DISTRICT APPLICATION FOR WATER Meter Size: �" / �� Service Address: �✓`, O'J �=1 `'"r� f' {(� _ NumbcrofUnits: �� Meter will be used for (check all that apply): � Domestic Irrigation Fire Service AccL No.: q � an Fire Line I hcreby appl)' for watcr scrvicc and agrec to bc govemed, in accordancc with the resolutions, rulcs and regulations of thc MUKILTEO N'ATER DISTRICT (M WD) penaining to water service, now on c�reafter in effect. 7he undersi�ned as owner or representative of the herein-described prcmisr.s hcrcby agrccs as follows: (I ) The eonsumer agrces to insmll, opem�c and maintain at alI times, thcir plumbing system in complianec with the curtent edition of Ihe Uniform Plumbing Cod: as it penains m �he prevrntion o(contamination, and pmtection from ihemml expansion due to n closed system �hat could ocwr with the pmsent or fuwrc installation of 6ackilow� prcvcmcrs on thc consumcr's scn•icc and/or at plumbing fiztures. (?) The consumer a@recs to install all backllow� prcvention assemblies requcsied by the MWD, a�d �o maintain those backflow prevention atsemblies in good working order. 77ic assembiics shall be of a qTc, sim xnd mekc nppmvcd bp th: MWD and tnc Wuhington State Depanment of Hcal�h Authorip�. The asscmblics shall bc installcd in acwrdnncc with aIl slandards cslablishcd by Ihc M WD. (3) Thc watcr mUcr will nof bc intmllcd until a wamr usc survcy hu becn submiltcd by thc applicant mid thc Districls Cruss Cannection ConVol Spccialist has detertnined iPlhe wstomer �eill need m install a bacAllow prevenmr on Ihe cusmmer's side of the meter. (4) That iho cost of any exlension u(O�e x�ater tervicq renewal, « placemrnt or repair to rcach and srne the propetty described shall be bome by mysel( ot assi fns as owncr(s) of thc prcmiscs. (5) That all pipes, water measuring devices and other connection e�;uipment upstream fmm �he moter shall, aficr their installation, be and becnme the prop=ny of Ihc M Wi), subjccl lu all iB regulations pcttaining to x�a�cr scrvsc. (G) 'fhat afiu insmllmion, iCmctor or memr boa and appuncnmices are buried o: damagcd, W: ownar, will bc held msponsible and cherged for samc. (7) That tim �AWD, i�s omrers and a�enis, shall havc thc ri�Jit c: ingress and cgress to go upon ihe premiscs and propeny described hercin tbr the purposc o: insp:ction, conneciing or disconnecting �he service or for such other purposes aa Oie service may «quire. It is aiso undersrood durinb ihe timo that any o( ihe waler mains muy be out of scrvice hy rcacon of any emergency or improvemen6 authori�rd Ay the MWD, in any sueet or othc localion in which thcy mny Fave 6ecn laid, Ihe MWG will not hc requircd to fumith water Juring Ihe pmg¢ss of such impmvcmenLs to any consumer v.noso supply may Wus bc � cut oil; ur bc Iia61c fnr any Jmnagcs far its failurc In do so. (R) � That Ihc 61\4U shall havc thc righ[ tn change Oic ratcs at any limc by Rcsnlulinq to Icmporarily disconlinuc thc scrvicc to wnsumcts, and m install tlie me�cr(s) to ngistcr thc water cnnsumcd. 7Lc M WD shall not bc hcld liablc for damagc by xroter or olher cause resulting from de@ctivc plumbing or applianccs installcd hy thc ox�ncr nr occupant on thc premises suppiics �vi�h Watcr, and thc fact �hat agcnts o(Ihc MWD may havc inspc:tcd �hc plumbing anJ upphanccs shall not hc plcad as a h5sis lor rccovcry in cacc of damagc as afnresaid. If thc suppl� of watcr shnll (ail or bc inlcrruptcd by rcucon o( accident, loH� pressure or other causc whalcoerer, lhe MN'D shall nnt bc hcid liable for damages nor shall such failum or imertuption for eny reuona6le timc be h:ld to constitute a breach uf contract on tlic p:ut o(�he MWD or in any way rclicve the wnsurc.cr, whether tenant or owner, fmm pedortning !h: obligation nf suzh tenant's or o�vner's rnntract. Wmer shall b: used by appiicant only on the premises described herein. A new application shall be filed slmuld x�mcn c� JcshcJ for olhcr prcmiscs ahhough locaicd on I:uiJ dcscribcd hcrein. (9) 'Pha[ Ihe 11[N'll rcenmmenJs installalinn nfa prcssurt regulating vuh'e• Applicnnt aeknox�ledges informe�ion as lo the rtcommenJelion end . nssumes full^rc�pYpsibility for installing ur failing In install a pressurc rcFulaling ralvc nn lhe walcr syslem �o pro�cc� it from high I'^�� pressure. �� INT. — �(111� TLc A1N'U utllixcs d¢ck roWcs at �hc mcicr lo prcrcnt e�:ucr returning In (6c Uistric�s mains Thc �iWD rccnmmcnds installa�ian of a Ihcrmal expansion tanA tn prcecnt excessi.�c pressure builJ-np amsed br Oir e�aler heaten Applican�mcLnpx�lydges informatian as to Ihc recommenduliun and bssumeti full responsibililr (nr installing or (�iling in inslall a Ihcrmal ezpnnsion tanl:. �� /� t 1\T. I J w+ � i.- ' i-- SERVICEADDRHSS: I L-� =�` �, 1`, ��--�.� LOTNO.: 6LOCF:: CITY/STATE/l.IP: (,.. '... J ON'NHR'SKAML: � L�- t O\i'NfR'S ADDRES$t I C CIT57STA'('"'�LIP:'= Y'..-: 7'hc prcmiscs arc �o be uscd av a SGRVICB7l'1'E�. � Dcvclnper Installcd: � District Insml icd: Dislricllnstallcd Pu�urc: _. PLAThAME: � ��-- LtGAL DGSCRII'TION: � �.— � �I I � `! .-:.��:-�% OLUGPGIdA71TIS5UEDBY: �� T�'�I Li�E INFOILMATION LETfGR GIVEN: CIIARGGS ( I) Scn�icc installation 6�. conncction ch:ugc ('_) Geneml Fu:ilities comiectinn chugc (3) Othcr Tmal nmount received with upplication S ��1.G1 S �"iiJ�.`1l� S �, ��' �� . .^:� IT IS UNDGRSTOOD that this Applicaiian, al�hough sipncd, shall not 6c binding upon the MUI:ILTEO N'ATER DISTRICT until epproved by the DISTRICT. t, the unJersigned, m�ner (or representatice) of �he propett}� Jescribed u6ove, dn I�c¢by make npplication for installation of a�/ �� -inch diametar water suppiy sen�ice cunqcclinn, includin!: appwtenmices, and nll necessyn•Jahora�my expenses. pamdthfs_�� dayof : Y�_i-il, ,=v-..�. �. APPLICANTS' SIGNATURE: � � � Applic�nt's Namc (pleasc pri�rt): —� ": / Applic:mPs AJJress & i'honc Numbcr. i�� �i �'i �%/ /; PAID t`y�� r _:J� n ? il . CROSSCONNGCTIONCONTROLSUMA1ARl'ASSESSMEMDACAFLOR'RGQUIRGD^ (�11' S ,� NO �/ 14�� "��-n t,:�rT-" r"-"!`1� l}�pe of Device: Size of Device: CCS Initials: Date: �� AI'!'ROYC.D: i11U1: O �PATGR UISTRICI' py.; l �: - �� '�.i— Date � � ��-�� IssuedDy:...� �.