10724 21ST PL W 2018-01-02 MF Import

C 4a MUKILTEO WATER DISTRICT APPLICATION FOR WATER Meter Size: -� �I I Service Address: a L( a I T ! V\)� J Acct. No.: _ Numberot'Uniw� 'Meter will be used for (check all that apply): K Domestic Irrigation Fire Service Fire Line I hereby apply for water service and agree to be governed, in accordance with the resolutions, rules and regulations of the MUKILTEO WATER DISTRICT (MWD) pertaining to water service, now or hereafter in effect. The undersigned as owner or representative of the herein -described premises hereby agrees as follows: (1) The consumer agrees to install, operate and mam=d: et all times, their plumbing system in compliance with the current edition of the Uniform Plumbing Code as it pertains to the prevention of contamination, aid protection from thermal expansion due to a closed system that could occur with the present or future installation of backflow preventers on the consumer's service and/or at plumbing fixtures. (2) The consumer agrees to install all backflow prevention assemblies requested by the MWD, and to maintain those backfiow prevention assemblies in good working order. The assemblies shall be of a type, size and make approved by the MWD and the Washington State Department of Health Authority. The assemblies shall be installed in accordance with all standards established by the MWD. (3) The water meter will not be installed until a water use survey has been submitted by the applicant and the Districts Cross Connection Control Specialist has determined if the customer will need to install a backilow prevcnic-on the customer's side of the meter. (4) That the cost of any extension of to water service, renewal, replacement or repair to reach and serve the property described shall be home by myself or assigns as owner(s) of the premises. (5) Thatall pipes, water measuring devices and other connection equipment upstream from the meter shall, after their installation, be and become the propcny of the MWD, subject to all its regulations pertaining to water service. (6) That after installation, if meter or meter box and appurtenances are buried or damaged, the owner, will be held responsible and charged for same. (7) That the MWD, its officers and agents, shall have the right of ingress and egress to go upon the premises and property described herein for the purpose of inspection, connecting or disconnecting the service or for such other purposes as the service may require. It is also understood during the time that any of the water mains may be out of service by reason of any emergency or improvements authorized by the MWD, in any street or other location in which they may have been laid, the MWD will not be required to furnish water during the progress of such improvements to any consumer whose supply may thus be cut off, or be liable for any damages for its failure to do so. (8) That die MWD shall have die right to change the rates at any time by Resolution, to temporarily discontinue die service to consumers, and to install de meter(s) to register the water consumed. The MWD shall not be held liable for damage by water or other cause resulting from defective plumbing or appliances installed by the owner or occupant on Ole premises supplies with water, and the fact that agents of the MWD may have inspected Ole plumbing and appliances shall not be plead as a basis for recovery in cast of damage as aforesaid. If die supply of water shall fail or be interrupted by reason of accident, low pressure or other cause whatsoever, die MWD shall not be held liable for damages nor shall such failure or interruption for any reasonable time be held to constitute a breach of contract on the part of the MWD or in any way relieve the consumer, whether tenant or owner, from performing the obligation of such tenant's or owner's contract. Water shall be used by applicant only on tte premises described herein. A new application shall be filed should water be desired for other premises although located on land described herein. 19).'rhat the MW'D recommends installation of a pressure regulating valve. Applicant acknowledges information as to the recommendation and �--, assumes full responsibility for installing or failing to install a pressure regulating valve on the water system to protect it from high ( .�~!.•t pressure.'' i INr. U 1� The MPt'D utilizes cheek valves at the meter to prevent water returning to the Districts mains. The MWD recommends installation ara thermal expansion tank to prevent excessive pressure build -cep caused by the water heater. Applicant acknowledges information as to the recommendation and assumes full responsibility for installing or failing to install a thermal expansion lank. INT. SERVICE ADDRESS: - .Y LP J I`"', �� 1 .r� LOT NO.: _BLOCK: _ CrrY/STATFJLIP: L -� r - `1r v � 0l� PLAT NAME: OWNER'S NAME: rl r-� - S rl z -mow LEGAL DESCRIPTION: r— =Fr- l/ OWNER'S ADDRESS: rC� PJ ax ICJ CITY/STATFILIP: l.� ei` C� t `-I c (Q BLDG PERMIT ISSUED BY: ' �' f O� V I $,, The premises are to be used as a TJ INFORMATION LETTER GIVEN: SERVICE TYPE: CHARGES: Developer Installed: X (1) Service installation & connection charge S �. D 0 District Installed: (2) General Facilities connection charge S h ` L •C O -.District Installed Future: (3) Other S Total amount received with application S .r /' C .J IT IS UNDERSTOOD that this Application, although signed, shall not be binding upon the MUKILTEO WATER DISTRICT until approved by the DISTRICT. J 1, the undersigned, owner (or representative) of the propcny described above, do hereby make application for installation of a / L/-inch diameter water supply service canine on, including appunen_mces, anJ all necessary bpr at my expenses. Dated less / day of�? Cr~ A 'APPLICANTS' SIGNATURE: -= ��. — !- '^ ' - PAID Applicant's Name (please print): Applicant's Address & Phone Number: .- —T-, SED 12006 V tdlKTEO WATER DISTRICT f CROSS CONNECTION CONTROL SUMMARY ASSESSMENT BACKFLOIV REQUIRED/IFS-- /' NO Type afDevice: Sim oCDevice: CCS Initials: Date: � �l� � APPROVE MUKILTEO WATER DISTRICT By':�� Dale: �� 9'" %��6 Issued By: J�