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City of Puyallup Engineering Services 333 S Meridian Puyallup WA 98371 Tel (253) 841-5577 Fax (253) 840-6678 www.cityofpuyallup.org Application for Extension or Connection of Water or Sewer Service Outside Puyallup City Limits Applicant Information Name: Mailing address: Telephone number: Alternate number: E-mail address: Owner Information (If applicant is not the property owner) Name: Mailing address: Telephone number: Alternate number: E-mail address: Submit proof that the applicant has legal authority to act on behalf of the owner with respect to the application. Property Information (Property for which the applicant seeks a water or sewer service connection or extension) Address: Assessor’s tax parcel number: New structural area in s.f.: Total affected site development area in s.f.: Submit an 8.5 x 11 site plan showing existing and proposed new construction. Type of requested service: Residential water Residential sewer Commercial water Commercial sewer Rev 5/15 ---PAGE BREAK--- Description of the project for which service is sought: (The project description shall be sufficiently detailed to enable the City to determine whether service is available, and to address any related issues, such as those concerning usage, supply line location, connections, meter type, supply volume and pressure, fire flow, and other related issues. Please attach additional pages, if necessary.) A construction permit accompanies this application: Yes No Submit a construction permit that has been duly issued to you or your contractor by the appropriate county and/or political subdivision for your proposed project on the above-identified property. The permit must allow for the construction of a side sewer and/or water service. An application for a construction permit accompanies this application: Yes No If the appropriate governing agency has declined to issue you a permit until the City of Puyallup provides a water or sewer service availability letter, then as a substitute for a construction permit, submit the substantially complete construction permit application with its supporting documentation. The appropriate application fee accompanies this application. Please check: Small: $690.00 Less than 10,000 s.f. of new structural area or 20,000 s.f. total affected site development area Medium: $1,250.00 10,001-19,999 s.f. of new structural area or 20,000-39,999 s.f total affected site development area Large: $1,890.00 20,000 s.f. or greater of new structural area or 40,000 s.f. or greater of total affected site development area I declare, under penalty of perjury, of the laws of the State of Washington, that the foregoing is true and correct. Dated: in Washington Applicant Signature Rev 5/15