Fillable City of La Pine PO Box 2460; 16345 (City of La Pine)

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City of La Pine PO Box 2460; 16345 (City of La Pine)

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{14323234-00559447;1}
City of La Pine
PO Box 2460; 16345 Sixth Street, La Pine, Oregon 97739
Telephone No.: 541-536-1432; Facsimile 541-536-1462
Application for Water and Sewer Services
The applicant hereby applies for water and sewer services from the City of La Pine. Please complete, sign, and return this
application prior to the date water and sewer service is requested.
Date of Application: _______________________________ Date of Service Requested: _____________________________________
Applicant’s Name: _________________________________Home Telephone No.: _________________________________________
Service Address: __________________________________ Billing Address: ______________________________________________
Employer: _______________________________________Employer’s Address: __________________________________________
Work Telephone Number: __________________________Email Address: _______________________________________________
Applicant is the [ ] Owner [ ] Manager/Agent [ ] Tenant Have you received utility services before from the City? [ ] Yes [ ] No
If yes, when were the utility services last provided: ______________________ Location of Prior Services: _____________________
If utility services will be in the tenant’s name, the property owner must provide the following information and sign the agreement
below:
Owner’s Name: ___________________________________ Owner’s Address: ____________________________________________
Mailing Address: __________________________________ Work Telephone No.: _________________________________________
Home Telephone No.: ______________________________ Email Address: ______________________________________________
PLEASE NOTE
A deposit equal to $150 is required on all accounts. Customers will have any deposit credited to their account after at least 12
months provided the account is not delinquent. If the applicant moves, the applicant must contact the City in order to have the
utility services removed from the applicant’s name. The applicant will also need to provide a forwarding address and telephone
number. In addition, there is a $35.00 setup fee on ALL new accounts for administration fees.
AGREEMENT AND SIGNATURES
The applicant hereby requests that the City provide water and sewer services to the property identified above. The applicant will be
responsible for all charges for services and compliance with all rules, regulations, and ordinances of the City, including, without
limitation, City Ordinance Nos.: 2015-04, 2015-05, and 2015-06, all as now existing or hereafter amended, adopted, promulgated,
and/or established from time to time.
_____________________________________ ____________________________________
Applicant’s Signature Date
The owner agrees to the following: (a) if the applicant fails to make any payments in accordance with the rules, regulations, and
ordinances of the City, including, without limitation, City Ordinance Nos.: 2015-04, 2015-05, and 2015-06, all as now existing or
hereafter amended, adopted, promulgated, and/or established from time to time, the owner will be jointly and severally liable to
the City for the full payment thereof, including, without limitation, any late and/or penalty fees; and (b) by signing below, the owner
consents, for purposes of ORS 91.255 and otherwise, to the City’s transfer of a claim against the applicant to the owner.
_____________________________________ ____________________________________
Owner’s Signature Date
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City of La Pine PO Box 2460; 16345 (City of La Pine)

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Completed 23 January 2021

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