The undersigned representing himself as the owner of property located at ______________, hereby makes application for connection to the water system of the village for said property, and in consideration of the furnishing of said service covenants and agrees as follows:
1. I agree to abide by all rules and regulations as specified in and by the ordinances of the village now in effect or enacted and passed from time to time providing for the regulation of service furnished by the village, it is further acknowledged and agreed that the undersigned, his heirs, executors, administrators, successors and assigns shall pay all charges for connection fees and water usage which shall become due as the result of the connecting of water mains and furnishing of water service to the above property, and that all such charges and fees for water service rendered to the property, together with penalties, if any, and the costs of collection are to be considered and become a charge against the property, the lien so created to be enforced in accordance with the ordinances of the village.
2. All bills for the aforesaid charges are payable on or before the due date following the receipt of said bill and if not paid, are subject to a ten percent (10%) penalty.
3. Each and all of the agreements and covenants herein contained shall run with the real estate above described whose present owner is signatory to this application.
4. I understand that making this application, I am to await installation permit and instructions therewith.
5. SERVICE CONNECTION FEE: $____________ is enclosed herewith, payable to the village.
6. Permission is hereby granted to the village and its authorized representatives at any reasonable time to enter the premises of the applicant and any portion thereof for the purposes of inspecting all connections appurtenant to the water system.
CONNECTION MUST BE INSPECTED BEFORE BACKFILLING
SIGNATURE ____________________________ _____________________________________
(STREET NUMBER AND NAME OF STREET)
_____________________________________
(VILLAGE, STATE AND ZIP CODE)
_____________________________________
(TELEPHONE NUMBER) (DATE)
Do not fill in the MAIL BILLS TO: (_____________________________________
spaces to the right (NAME)
if the information is the same as the (_____________________________________
applicant above. (STREET NUMBER AND NAME OF STREET)
spaces to the right (NAME)
if the information is the same as the (_____________________________________
applicant above. (STREET NUMBER AND NAME OF STREET)
(
(VILLAGE, STATE AND ZIP CODE)