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APPLICATION FOR SERVICE PASCO COUNTY UTILITY SERVICES (727) 847-8131 NEW PORT RICHEY 7536 STATE STREET, SUITE 118 (813) 235-6012 LAND O'LAKES P.O. BOX 2139 (352) 521-4285 DADE CITY �i�''� � ;��.f��"-t NEW PORT RICHEY, FL 34656 FAX(727)847-8972 I, THE UNDERSIGNED, REQUEST THAT WATER AND/OR SEWER SERVICE BE TURNED ON AT THE BELOW PREMISES,TO BE SUPPLIED THROUGH A METER,AND I AGREE TO PAY ALL MONTHLY BILLS WITHIN FIFTEEN (15) DAYS, AT THE ESTABLISHED RATES, FOR ALL WATER AND/OR SEWER SERVICE RECEIVED AND/OR CONSUMED FOR THE PERIOD FOR WHICH THE BILL IS RENDERED. I FURTHER AGREE TO OBSERVE ALL RULES AND REGULATIONS PROMULGATED BY PASCO COUNTY UTILITY SERVICES AND WILL NOT PERMIT ANY ADDITIONAL TAPS OR LINES TO BE MADE OR ATTACHED TO THE WATERLINES ON THE BELOW PREMISES. IN ADDITION, I UNDERSTAND THAT THE SERVICE BEING APPLIED FOR BELOW IS TO SERVICE ONLY THE PREMISES LISTED ON THIS APPLICATION, AND ANY NEW STRUCTURES ON SAID PROPERTY CANNOT BE PROVIDED WITH WATER/SEWER SERVICE THROUGH THE SAME WATER METER. IT IS AGREED THAT ANY AUTHORIZED AGENT OR EMPLOYEE OF PASCO COUNTY UTILITY SERVICES SHALL HAVE ACCESS TOTHE BELOW LISTED PREMISES AT ANY AND ALL REASONABLE HOURS FOR THE PURPOSE OF CONDUCTING NORMAL BUSINESS WHILE WATER AND/OR SEWER SERVICES ARE BEING SUPPLIED TO THE SAID PREMISES, DESCRIBED BELOW, WITHOUT BEING LIABLE FOR EITHER PERSONAL OR PROPERTY DAMAGES OF ANY KIND WHATSOEVER. IT IS FURTHER AGREED THAT IF THERE IS AN UNPAID BALANCE DUE ON MY ACCOUNT FOR ANY WATER AND/OR SEWER SERVICE CONNECTION, IT MAY BE TRANSFERRED TO THIS ACCOUNT FOR IMMEDIATE PAYMENT. IN THE EVENT OF NONPAYMENT OF ANY WATER AND/OR SEWER BILL DUE FOR THIS OR ANY OTHER CONNECTION, ALL WATER AND/OR SEWER SERVICES CAN BE DISCONNECTED BY UTILITY SERVICES AND BEFORE SAID SERVICE IS RECONNECTED, ALL OUTSTANDING BILLS MUST BE PAID IN FULL IN ADDITION TO A RECONNECTION FEE AT THE PREVAILING RATE. THE RECONNECTION FEE IS PAYABLE IN ADVANCE, BEFORE SERVICE IS RESTORED, EVEN IF METER HAS NOT BEEN REMOVED OR DISCONNECTED. IF APPLICABLE: I AGREE TO PAY ANY AND ALL FEES BEFORE THE WATER IS TURNED ON AT THE PREMISES. I WILL PAY ALL DAMAGES TO ANY OF UTILITY SERVICES PROPERTY AND/OR METERS, AND IF NOT PAID UPON PRESENTATION OF BILL,THE WATER MAY BE DISCONTINUED. THIS CONTRACT REMAINS IN FULL FORCE AND EFFECT UNTIL WRITTEN NOTICE HAS BEEN RECEIVED BY PASCO COUNTY UTILITY SERVICES TO DISCONTINUE SERVICE. THE DEPOSIT MADE WITH THIS APPLICATION WILL BEAR NO INTEREST AND WILL BE APPLIED TO THIS ACCOUNT UPON WRITTEN NOTICE TO DISCONTINUE SERVICE, OR AFTER APPLICANT HAD FULFILLED TWENTY-FOUR (24) MONTHS OF CONSECUTIVE SERVICE WITH NO LATE PAYMENTS OR DISHONORED CHECKS. PASCO COUNT�Y UTILITY SERVICES IS PERMITTED TO FILL IN THE BLANK(S) FOR THE FOLLOWING PROPERTY,TO-WIT: �f�.,�� "� ACCOUNT NO.: ��'� ��,r:a -i.�k t��--��:�---:: � �' �' 1�r DEP SITDATE: �� '��`�" �� NAME: i�; G_,�9'4z s�+�t �"E.i3?�t I�ir� �f�{�� f�,�(�t,:f.��`,� �._�r��"''�� ,. LAST DEPOS�T �EE: � °�� ( ) (FIRST) (INITIAL) {� ,�/J�� ti�.�1��,,r'� SERVICE -- �`"` '°"'i.>� ��6_.1'� �:r��i:_�J A�;�� f: �� .ti � ��- ADDRESS: �� ' a ��✓� METER FEE: °�'''� ��-� SUBDIVISION CODE: ``'��' SUBDIVISION: `�� ``'�-��'�� m�.:�i� T� RN-ON F�E: _ � a _ 7�� i 'i:l..,. PHONE: �::�z�_;.3�t�—a,.�t:x"1 �-� � �.�.��`J�' ;�',d��. i��"� OWNER OR TENANT: l�THR IMP�CT FEE: BILLING/MAILING �;;.`r� �� , �� ;; ADDRESS: �''��-k '� �'�-�� 'Y� SEW�R IMPACT FEE: ��`�-��`� CLOSING/SERVICE DATE: ;�� ; �� `''�"�`�'�'��-�'Y`�- I HAVE READ THE ABOVE AGREEMENT AND (CITY) (STATE) (ZIP CODE) UNDERSTAND THE CONTENTS THEREOF: ��•�..-i.... a` ;'�f~ ( �� 1''.. ��'��, (COUNTRY) BY: ._.k.- �L'�..� .,�}'�. .,.,�,,.,, (TYPE OF BUSINESS , (APPLICANT� '�� ) � � � - f ' '� ; ` .%-..... '�.a�n ��, � PASCO COUNTY UTILITY DIVISION, BY: ��' i..t-Sr DATE:_ �'il r'' �%�1`7�' PC95115020/A _ _ _ _ _ _