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MUKILTEO�1'ATGR DISTRICT C
<br /> APPLICATION FOR R'ATE2
<br /> Meter Size: '�" Scrvice Address: ' ��''�'`�''- �='�f �"� -`' � Acct.No.: � p � �'1
<br /> Number of Units: �
<br /> 'Meter will be used for(check all that apply): �' Domestic Irrigation Fire Service Fire Line �
<br /> 1 herehy apply for wutr scrvice and agrec to be govemed, in accordance with thc resolutions,rules and regulations of the MU[:ILTEO R'ATER
<br /> DISTRICT(MVVD)periaining to water scrvice,now or hereaftcr in effect. The undersigncd as o�mer or reprosentative oTthe herein-described
<br /> prcmis�s hcrcby agrec;as Collows:
<br /> Q) Thc mnsumc;agrccs m install,operatc and maintain at nll timcs,thcir plum6ing system in compliance with tlie artcnt edi�ion of thc Uniform Plumbing
<br /> Codc as it pertains ro tlie prcvcntion olcontamination,and pmtection fmm thcrtnal expansion due m a closod systcm that could occur e�ith the praent or
<br /> fuWrc inslallation of backOoH'prcvrntcrs on Ih:cunsumds sarvicc ond/ar x!plum6ing fixmres.
<br /> (?? 'I'ha consumu agrees m install all ba:kOms prevcn[ion azsemhlics rcqucstcd by thc MWD,and to m¢intain those ba:ktlow prevention esscmblics in good
<br /> working order. 'fhe azsemblies shail be of n rype,sim and maF;c approved bc the MND and the q'uhington State Depenmrnt of Henlih Authonty. The
<br /> asscmblics Shall bc installeJ in accordancc�cith all ttandards csta6lishcd by Ihc MWD.
<br /> (3) Thc u�atcr mctcr wilt not b:installcJ until n u�atcr usc survcy has bccn su6mittcd by thc applican:nnd thc DisvicLc Cross Conn:ction Convol Sp:cialis�has
<br /> dcicrmincd if th:cusmma will nectl m install a back0ow preventcr on ihc wstomer's sidc of 1he mcter.
<br /> (4) Tha[ihc cust of:m}�cxtcnsion of II¢walcr scn�icc,rcncwal,replaccmcnt or repair to rcach end smc�he propert}•descri6cd shall bc bome by m}•sel(or
<br /> assigns as ouncr(s)o(thc prcmiscs.
<br /> (5) Thzt aIl pipes,wator meacuring devi:cs and oth:r connection eqwpmen�upstrcam Gom��e memr shall,a(tu�icir installntion,be arid hecome the pmpeny of
<br /> the M WD,subjcct to all ila mgulntions pertaining m watcr scrviee.
<br /> (G) Thac aftcr installation,iCmctcr or mc�cr box and nppurtcnwccs ar:buricd or Jama@cd,Ihc owncr,will bc hcld responsibic and chargcd for sam:.
<br /> (7) That Ihe MWD,its o}ficers and aecnLs,shall have Ih_rieht oCingress and egmss to go upon the premises ond property dcscri6ed hercin fnr tl�e puq�ose of
<br /> inspcction,connecting or disconrecting Ih=scrvicc or for such olhcr purposcs as Ihc scrvice map rcquim. II is nlso understood during Ihe timc that any oC
<br /> lhe water main;ma}�be out of service by rcason of any emergency or improvemrn�c authori�cd by the MWD,in any sucet or other lo:ation in which they
<br /> map have becn laid,thc MN'D will not bc rcquireJ�o fumish��ator Jurinc ihc progrus oi su:h improvements to nny consumcr whosc supply may thus h.e
<br /> cut o(f,or bc liablc for any dama�cs for ilc failurc to do so.
<br /> (G) Thz[O�c MR'D shall havc th:right to chnnge Ilte ratet at any lim:br Rcsolution,lo tcmporarily discontinue Ihc service to consumcrs,and lo insiall Ihc
<br /> m:ter(s)m rcgistcr thc water wnsumed. The tdWD shall not hc hcld liable for damagc by aatcr or othcr causc resWting fmm dcfcctive plumbing or
<br /> opplianccs instalicd by thc m�mcr or occupant on Wc prcmises supplics w�ith watcr,and thc fact ihat aocntc o(tnc MWD may havc inspec�cd tl�c plumbing
<br /> and applianccs shall no:bc plead as a 6uis for«cnecry in cac:of damag:ns a(orcsaid 1lthc supply aC��atcr shall fail o:bc interruplcJ by rcuson o(
<br /> necident,low prcssure ur otlier cause�sha•soecer,�t.MWD shall not bc held liuble for damages na shall such failurc or inlerruption for any rc�uonablc lime
<br /> bc hcld�o constiwtc a bmach ofconuatt on th=pan of thc MND o:in anp way rclicvc 6ia consumcr,whetncr tenant or oener,from perfonning�hc
<br /> obliEation of such tenanC�or o��ner's contract N'mer shall b:used by applic;urt only on the premises described herein. A new�application shall he filed
<br /> should waler be JesireJ(or o�her prcmises ulthourh Incatcd on land described herein.
<br /> (9) That�hc A1K'D rccommrndx insiallalinn nf a pressnrc rcgula�ing vnWc. Applicant acknuxicdgcs infurmation ns ln�hc rccummenJe�ion nnd
<br /> ussumes(ull�Gspnmibilih�(nr installing nr fuilin�Iu install a pressnre regulnting��aivc un t6e wn�cr system in protect it from hish
<br /> � , pressurc. IKP.
<br /> � (10) Thc �1R'D ulili�ss checl;valves at Ihe me�er tn prevent water rctnrning(O lI1C DISIfIC(5 f11:11115. TIIC I1I�VD fC[OIIIf11COfI51115f0IIN�lOp OCO ILCf rtIAI
<br /> expnnsimi tonk lo prevent exccssive pressure bnilJ-up causeJ br Ihc r��aten c�atee Appiicant�eknox�ledees information as to thc rernmmendalinn
<br /> xnd assumcs full responsi6ilih'fnr insmlling nr failin�lu insmil n lhrrmal czpnnsinn lank_,IAIT.
<br /> / "JCi.`..' :' .� , - ). r;
<br /> SERVICGADDRESS'' : � � " �- LOTNO.: � BLOCK:
<br /> ,:ili /_i..% '/i� . � 7 _ .�.
<br /> CITY/STATFJZIP: �� � � � PLATNMIE: "
<br /> � �.' �. ;��.,,y
<br /> OWNER'S NM1E: - � � � � � LEGAL DESCRIPTION: -
<br /> OWNER'S ADDRESS:� � `" � � '� �
<br /> CITI'lSTA'fFILIP: - � "� � � f3LDG PLI:M1IIT 1SSUED 6Y:
<br /> 1'hc premisu arc ro be uccd as❑ " r INFOR�L�TION LGTCGR GIVE�:
<br /> SfRVICGTI'PF.' CHARGES: . f f�
<br /> ��/•,i,� � �.
<br /> Dcveloper Insmllcd: �__ (I)Servicc installatian S connection chargc S -
<br /> District Insmllcd: (2)Gcncral Facilities conncnian charge S `��— �� �� OB
<br /> Disvict Ins�alled Fmure: (3)Olhcr S � /Il/�{�r�.
<br /> Totnl atnount rcceivcd witli applicatian S �'J�'`✓ � _ "/'V V ��
<br /> IT IS UNDERSI'OOD Ihat Uiis Application,al�hough signed,shall not b:binding upon tli-MUI:IL7'EO 11'A i E2 DISTRICT until approvcd 6}•ihc DlSTRICT.
<br /> J'«�
<br /> 1,the widersigned,o�tner(nr reprcsentatiec)of6i:propene descri6eJ above,do hereby ma1:c upplicntion for instsllation of n -inch diameter water supply
<br /> servim mnnection,including appunennnees,nnd nll necess�up labo:s�my expenses.
<br /> Dalcd this day o( - -
<br /> 1 __ __��
<br /> APPLICMTS'SIGNATURE:- � ' "'
<br /> Appli:ant'st�an,_(plc�scprint): __ � � -,.. - 1'- - - , " - .
<br /> � ~ ._:. � \:� i -' .- � �,: ' :i :�.
<br /> Applicant's Address&Phon:Numhcc �-_ --- � - - -- � ' '" �
<br /> L'
<br /> � •CROSS CONNECiIOh COt.'fROL SUMMAAI'ASSESSMENT BACi:FLOH'REQUIREU?_xES � NO �
<br /> T)p:nfDcvitt: Siz^a(D;vicc: CCSlnitials: ����— Date: ''/"i�"✓
<br /> API'HOl'$py � p1UF:ILTEOIYATERDI5TRICT �J
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<br /> [tv: ��'y�� Datc: i'� '/� ��"�✓ IssueA Ay: � '�`-
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