Approved by: ____________________________________

Subdivision Number: ___________________

AP Number: _____________________________

Block: Lot: ___________________________

Intended Use of Service: [ ] Residential [ ] Commercial [ ] Other

CREDIT INFORMATION

Applicant Name: __________________________

Mailing Address: __________________________

Home Phone: _____________________________

Work Phone: ____________________________

Applicant's Drivers License#: _______________

Spouse Drivers License#: _________________

Social Security#: _______________________

Spouse Social Security#: _________________

Employer Information: ______________________

Name: _______________________________

Address: _____________________________

City, State, Zip: ________________________

Phone: _______________________________

Spouse Employer Information: _____________________

Name: _______________________________

Address: _______________________________

City, State, Zip: __________________________

Phone: _______________________________

*** IF THE APPLICANT IS THE OWNER, GO TO CERTIFICATIONS SECTION OF THIS FORM ***

Property Owner: _______________________

Phone: _______________________________

Address: ____________________________________

City, State, Zip: _______________________________

Property Manager: ___________________________

Phone: _______________________________

Address: ____________________________________

City, State, Zip: _______________________________

*** For Brooktrails District Use: ***

Date of Architectural Approval: ____________________________________

Mendocino County Building Permit Number: ____________________________________

Connection Fees paid with this application: Water: $ _____________ Sewer: $_______________


Check Number: _______________________________

Section 2-205(a) of District Ordinance No. 112 provides as follows:

Construction Service. For all new service connections, where a County building permit is also required, the connection is considered to be a construction service until: 1) The County Building and Planning Department issues final approval for occupancy, and 2) the District Architect issues a compliance certificate certifying that all conditions of the development review approval have been satisfied. All construction service water usage shall be paid at a rate established by the Brooktrails Board of Directors. When items 1) and 2) above have been met, the service will automatically convert to regular water service. If regular water service has not been obtained in one year from the date of the construction service issuance, all water service shall be terminated unless an extension approval has been granted by the General Manager. To obtain an extension approval, applicant must submit a written explanation as to why the project has not yet qualified for regular water service. The General Manager has full discretion in granting an extension approval.

Certifications:
Making this application, we agree to conform to all District ordinances, rules, and regulations regarding utility services. We understand and agree that water service may be discontinued for violation of the rules and for failure to pay in full the bill or utility services by the 20th of each month. We have read and understand the following statements regarding service:

1. The property owner is responsible for all plumbing, equipment and appliances from the point of connection to the District's system.

2. The property owner is responsible for any damage to District utility facilities resulting from acts of the owner, tenants, agents, employees, contractors, licensees, or permittees.

3. The property owner is responsible for the installation of a shut-off valve near the water meter, a proper water pressure reducing device and a proper water pressure relief device in order to prevent damage to the premises and contents; a water backflow prevention device to protect the District water system, and a sewer backflow prevention device to protect the premises in case of failure of the District sewer system.

4. The owner and the applicant agree that the District shall not be responsible or liable for damages or injuries resulting from interruption in service, changes in water pressure or quality, sewer system blockages or other unforeseen conditions or circumstances. It is understood that the District offers no guarantees, warranties, or assurances regarding utility services and the quality of the water provided.

5. The applicant hereby agrees to pay to the District all charges and rates for the service provided pursuant to this application, including any costs related to the collection of amounts due. However, by law, the property owner is responsible for all unpaid amounts owing the District resulting from service provided to the premises, whether or not such service was requested by tenants or other agents.

We would like to have the water service established on: ______________________________.

We would like the water service: [ ] turned on [ ] left off.

*** A $6.70 START UP FEE WILL BE ADDED TO YOUR FIRST BILLING STATEMENT. ***

Signature of Owner: ________________________________________ Date: ______________________________________

Signature of Applicant: _____________________________________ Date: ______________________________________

NOTE: A 10% PENALTY WILL BE ADDED TO ACCOUNTS WHICH RECEIVE LATE NOTICES. THESE ARE MAILED OUT TWENTY DAYS FOLLOWING THE BILLING DATE. A $6.70 CHARGE WILL BE ADDED FOR THE 48-HOUR DOOR HANGER NOTICE (DELIVERED THIRTY DAYS AFTER THE BILLING DATE.)