Application for Utility Services (Water & Garbage)

2. Bluffdale City Utilities Application (Water & Garbage)

4. Billing Name*

   (Must be Home Owner)

5. Additional Name

   (Must be Home Owner)

7. Email Address*

8. Email Address

10. Address Where Services are Requested*

11. Rental

    1. Yes

    Check here if this is a rental and you want the tenant to get a copy of the bill.

13. Mailing Address (if different)

15. City

16. State

17. Zip

19. Phone Number*

20. Phone Number

22. Purpose of Application:*

    1. New Home
    2. Existing Home
    3. Commercial
    4. Other

23. Date of Closing*
    Date of Closing

24. Proof of Purchase*

    Include proof of Purchase - Closing Statement from the closing documents with name, address & date of closing. NO Real Estate contracts or deeds.

26. 

28. # of Trash Cans*
    -- Select One --123Commercial (no service)Call office for more than three cans

29. # of Recycle Cans*
    -- Select One --123Commercial (no service)Call office for more than three cans

30. # of Green Waste Cans (not required)*
    -- Select One --012Commercial (no service)Call office for more than two cans

32. Set-up Fee
    A set-up fee of $35 will be added to your first billing.

    A set-up fee of $35 will be added to your first billing.

34. License Information & Fee
    I, the undersigned, hereby apply for utility services from Bluffdale City for the above named premises and agree to pay any and all charges incurred for said services (including but not limited to culinary water, storm water, street lights and garbage collection) in accordance with rates fixed by Bluffdale City. Failure to pay my bill in full by the 25th of each month or having an excessive or extended balance, will result in an interruption or disconnection of service(s). I recognize and consent that a re-connection fee of $50.00 will be assessed. Payment in full of all outstanding charges, including the re-connection fee will be required before services can be restored. Damage By Customer: All damages or injury to the lines, meters or other materials of the city on or near the customer's premises caused by any act or neglect of the customer shall in the discretion of the city be repaired by and at the expense of the customer, and the customer shall pay all costs and expenses, including reasonable attorney fees, which may arise or accrue to the city through its efforts to repair the damage to the lines, meters or to other equipment of the department, or collect such costs from the customer. (Ord. 5-27-80-1, 5-27-1980, eff. 5-28-1980) Failure to pay said charges will result in interruption of services. I agree to pay all reasonable attorney fees and other costs incurred by Bluffdale City to obtain collection on this account, whether or not litigation is actually filed.

    I, the undersigned, hereby apply for utility services from Bluffdale City for the above named premises and agree to pay any and all charges incurred for said services (including but not limited to culinary water, storm water, street lights and garbage collection) in accordance with rates fixed by Bluffdale City. Failure to pay my bill in full by the 25th of each month or having an excessive or extended balance, will result in an interruption or disconnection of service(s). I recognize and consent that a re-connection fee of $50.00 will be assessed. Payment in full of all outstanding charges, including the re-connection fee will be required before services can be restored. Damage By Customer: All damages or injury to the lines, meters or other materials of the city on or near the customer's premises caused by any act or neglect of the customer shall in the discretion of the city be repaired by and at the expense of the customer, and the customer shall pay all costs and expenses, including reasonable attorney fees, which may arise or accrue to the city through its efforts to repair the damage to the lines, meters or to other equipment of the department, or collect such costs from the customer. (Ord. 5-27-80-1, 5-27-1980, eff. 5-28-1980) Failure to pay said charges will result in interruption of services. I agree to pay all reasonable attorney fees and other costs incurred by Bluffdale City to obtain collection on this account, whether or not litigation is actually filed.

36. Electronic Signature*

    1. I Agree

    By checking 'I Agree', you agree to acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.

38. Signature*

39. Date*
    Date

41. FOR OFFICE USE ONLY

43. Previous Owner
    __________________________________

    __________________________________

44. Account #
    __________________________________

    __________________________________

45. New Account #
    __________________________________

    __________________________________

47. Meter Reading
    __________________________________

    __________________________________

48. 

49. Date Cans Ordered
    __________________________________

    __________________________________

51. Date Setup
    __________________________________

    __________________________________

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field