CITY OF LAURIE P.O. BOX 1515 LAURIE, MISSOURI (573) (573) FAX APPLICATION FOR WATER AND/OR SEWER SERVICE

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1 CITY OF LAURIE P.O. BOX 1515 LAURIE, MISSOURI (573) (573) FAX APPLICATION FOR WATER AND/OR SEWER SERVICE EFFECTIVE DATE OF CHANGE OVER: NAME (OR BUSINESS NAME): NO. IN HOUSEHOLD: SPOUSE (IF APPLICABLE): MAILING ADDRESS: PHONE NO.: CITY: STATE: ZIP: S.S.N.: ADDRESS: PHYSICAL ADDRESS OF PROPERTY: TYPE OF SERVICE: COMBINED WATER/SEWER WATER ONLY SEWER ONLY TYPE OF USAGE: RESIDENTIAL COMMERCIAL PREVIOUS CUSTOMER: YES NO DO YOU: RENT OWN PLACE OF EMPLOYMENT: PHONE NO.: IF RENTING: NAME OF OWNER: ADDRESS OF OWNER: PHONE NO. OF OWNER: IF THIS IS FOR COMMERCIAL USE, PLEASE EXPLAIN TYPE OF USE: SIGNATURE: SPOUSE:

2 FOR OFFICE USE ONLY: ACCOUNT NO.: RATE CODE: READING SEQUENCE NO: EXISTING WATER METER NEW WATER METER OUTSIDE CITY LIMIT: YES NO EXISTING SEWER CONN NEW SEWER CONN EASEMENT ON FILE: WATER SEWER METER READING METHOD: VISUAL RADIO RESIDENTIAL COMMERCIAL COMBINED SEWER/WATER CITY WATER ONLY CITY SEWER ONLY FOR PREVIOUS CUSTOMERS: ANY OUTSTANDING CHARGES NO YES AMOUNT: WATER DEPOSIT AMOUNT: $50 - OWNER $100 - RENTER CASH CHECK CHECK NO.: $ COMMERCIAL METER S/N: I.D. NO. METER READING: IMPACT FEE: $500 $833 $1667 $2667 OTHER 5/8 & 3/4 1 1 ½ 2 AMOUNT INSTALLATION FEE: BACKFLOW REQUIRED: YES NO METER SIZE: 5/8 ¾ 1 2 PRESSURE REGULATOR: YES NO SEWER DEPOSIT AMOUNT: $50 - OWNER $100 - RENTER CASH CHECK CHECK NO.: $ COMMERCIAL AMOUNT INSTALLATION FEE: IMPACT FEE: $500 $833 $1667 $2667 OTHER GRAVITY CONNECTION PRESSURE CONNECTION PUMP HP: 2 2HH 5 DIAMETER: DATE OF INSTALLATION: START-UP: DATE WARRANTY PERIOD STARTS:

3 CITY OF LAURIE P.O. BOX 1515 LAURIE, MISSOURI (573) (573) FAX The undersigned, being the owner or occupier of land located within the jurisdiction of the City of Laurie, hereby enters into an agreement with the City of Laurie for a water service and/or sewer service connection, and agrees to the following conditions: For New Service Installations Only: 1. To become a user of the City of Laurie s water and/or sewer systems, I agree to tender the sum equal to the amount of the actual cost of the components and any other direct cost incurred by the City to make the connection to reimburse for the cost of these components and other direct costs. In addition to the amount tendered for the reimbursement of the meter, pump, required components, appurtenances and other direct costs I tender the amount of: Water Line Size Sewer Water ¾ $ $ $ $ ½ $1, $1, $2, $2, Other Other as an Impact Fee, as required by the Water and Sewer Rate Schedule Ordinances. I understand that the amounts for Impact Fees are for newly installed services and do not apply to existing connections to city services unless an upgrade in size is required. For All Customers: 1. I tender the following for: Owner water deposit $ Renter water deposit $ Owner sewer deposit $ Renter sewer deposit $ Commercial sewer deposit $ Commercial water deposit $ which is to be a deposit on said water and sewer connection. All money held as security deposit shall be refunded to user provided all terms of this agreement are met at the time of termination of said agreement.

4 2. I will pay the minimum monthly charge for the service connections from the time service is made available by the City of Laurie, and pay for usages over the minimum as set out in the Rate Schedule Ordinances adopted by the Board of Alderman. 3. The Laurie Public Works Department will read the water meters monthly, either physically or by estimate. A service bill for service used shall be rendered by the Public Works Department on or before the 5 th day of the month following the month in which the service is used, and the undersigned agrees to pay said service bill on or before the 15 th day of the month in which the bill is rendered, or be subject to a late charge of TEN PERCENT (10%). Failure of the Public Works Department to submit a service bill shall not excuse the undersigned from his/her obligation to pay for the service used. Failure to pay a bill by the first day of the month following the month in which the bill is rendered shall result in discontinuance of the service. 4. The service supplied by the City of Laurie shall be for the sole use of the undersigned; the undersigned agrees that he/she will not extend or permit the extension of pipes or lines for the purpose of transferring water or sewage from one property or another, nor will he/she share, resell, or sub-meter either water or sewage service to any other consumer. Each meter service shall supply water to only one residence or business establishment located within the jurisdiction of the City of Laurie. 5. If, after water and/or sewer service is made available, the same is discontinued or disconnected for any purpose, pursuant to the Use Ordinances or Rate Schedule Ordinances of the City of Laurie, reconnection shall only be made upon the conditions set out by these ordinances. 6. The undersigned agrees that he/she will make no physical connection between any private water and/or sewer system and the water or sewer system of the City of Laurie. Representatives of the Public Works Department may at any reasonable time come on the premises where the water or sewer service is being used for the purpose of making inspection to enforce this provision. Violation of this provision shall be grounds for disconnection of service. 7. The laws of the State of Missouri, the ordinances of the City of Laurie regulating water and sewer usage as presently existing, and as may be amended from time to time, are made a part of this agreement as though fully set out herein. 8. The undersigned agrees that he/she will grant an easement to the City of Laurie for lines and all appurtenances used for the transmissions of water and sewage over, under and across any interest he/she may have in real property in consideration for the City of Laurie accepting this application. 9. The undersigned agrees that this agreement shall be binding upon his heirs, executors, administrators and assigns.

5 10. By signing this agreement, the undersigned affirms that he/she is the actual owner, tenant or agent authorized to sign this agreement. SIGNATURE: SPOUSE (IF APPLICABLE): This agreement is accepted and executed on this day of, 20. City of Laurie, Laurie Water Department By: Olive Wood, City Clerk