Domestic Water Service Request - Residential (New Meter)_Ubaldo Ayon-signed REVDOMESTIC WATER SERVICE REQUEST – RESIDENTIAL (New Meter)
*Indicates required information to process your service request.
Location to Begin Water Service
*Type of Service Requested Water Sewer Irrigation
*Service Address :
*City and Zip Code:
*Assessor’s Parcel Number Lot number:
Billing Account Information
*Last Name:
*First Name – Middle Initial:
*or Company Name:
*Mailing Address: City, and Zip Code:
*Phone Number:Home: Work:
Fax Number: E-Mail Address:
Customer Contact Information
*Emergency Contact Name
*Contact Number:Work : Cell:
E-Mail Address:
Meter Sizing Information
*Domestic Water Demand *Maximum Flow at Meter (in gallons per minute):
*Minimum Pressure Required at Meter (in pounds per square inch):
*Fire Sprinkler Demand *Maximum Flow at Meter (in gallons per minute):
*Minimum Pressure Required at Meter (in pounds per square inch):
*Type of System
(please check one)
Multipurpose System (Combined Domestic & Fire System)
Stand Alone System (Separate Domestic &Fire Systems)
Please create a 4 to 8 character (letters and numbers) passcode for identification purposes. This passcode will be required
to allow you to process certain transactions over the telephone. PASSCODE:
Property Owners are responsible for payment of water bills. Owners may authorize tenants to receive and pay the bill; however,
responsibility for the account remains with the Property Owner. By signing this document, I certify I am the legal landowner of the
property identified as the service address above, all information is true and correct, and acknowledge and agree to all terms on the
back of this form. I assume all responsibility for any bills, costs, or fees associated with water service regardless of user or use. Upon
termination of the tenant’s account, the account will automatically revert to the owner’s name. I understand all bills are due and
payable within 30 days of billing, and a 1 ½ % interest charge will be assessed against all delinquent bills. At time of meter install
monthly water and sewer service fees will commence. *Initial
*Owner Signature:*Date Signed:
COACHELLA VALLEY WATER DISTRICT, 75-515 HOVLEY LANE EAST, PALM DESERT, CA 92211(760) 391-9600 Fax (760) 568-1789
Developmentservices@cvwd.org
WS-28DS-Rev. 12/10
CVWD USE ONLY: Account Number:
Owner Developer Contractor
Ayon
34
La Quinta 92253
44250 Goldenrod Circle
604081034
12/04/2023
UAJ
N/A
N/A
20
70
uayon@laquintaca.gov
76027527897607777051
Ubaldo Ayon
uayon@laquintaca.gov7607777011
7602752789 7607777051
78495 Calle Tampico, La Quinta 92253
City of La Quinta
Ubaldo
TERMS AND CONDITIONS
Coachella Valley Water District (CVWD) owns, operates, and maintains the portion of the water service line from the
water main to the outlet of the gate valve on the downstream side of the meter, check valve or backflow prevention
device (Service Connection). The Customer is responsible for the remaining portion of the service line to the
residential unit being served (Customer Service Line). The Customer Service Line includes separate domestic water
and fire sprinkler systems.
Property Owners are responsible for payment of water bills. Owners may authorize tenants to receive and pay the
bill; however, responsibility for the account remains with the Property Owner. By signing this document, I
acknowledge and agree to adhere to and abide by CVWD’s Regulations Governing Domestic Water Service
(Regulations).
Customer acknowledges that CVWD will provide a single Service Connection to Customer’s property identified in this
application (Property). In the event CVWD discontinues water service to the Property for any reason set forth in the
Regulations, including, but not limited to, failure to make payment when due, CVWD may, in accordance with the
Regulations, discontinue water service to the Property. If CVWD discontinues water service to the Property, there is
no water service for the residential sprinkler system. Customer assumes all risk of loss and damage to the Property,
including the residential unit located on the Property or injury to persons arising out of the termination of such water
service and hereby waives all claims in respect thereof against CVWD, including losses arising from or in connection
with the loss of residential fire sprinkler protection. In addition to the foregoing, Customer assumes all risk of loss or
damage to personal and real property due to backflow from the fire sprinkler system portion of the Customer Service
Line into the domestic portion of the Customer Service Line for any reason whatsoever, including without limitation,
any water quality exceedances.
Customer shall assume the defense of, indemnify and hold harmless CVWD from and against all actions, causes of
action, damages, demands, liabilities, costs (including, but not limited to reasonable attorneys’ fees), claims, losses
and expenses of every type and description (collectively, Costs) to which it may be subjected or put, by reason of, or
resulting from: (A) the design, construction, testing (including inspection to ensure that such system is operational),
operation, maintenance, repair and replacement of the residential fire sprinkler system located on the Property; (B)
the performance of or failure to perform of the residential fire sprinkler system located on the Property during
Customer’s ownership of the Property; (C) backflow from the fire sprinkler system portion of the Customer Service
Line into the domestic portion of the Customer Service Line for any reason whatsoever, including without limitation,
any water quality exceedances during Customer’s ownership of the Property; and (D) any death, injury, property
damage, accident or casualty caused or claimed to be caused by the discontinuance of water service to the Property
for any reason set forth in CVWD’s Regulations, including, but not limited to, failure to make payment when due,
including any Costs arising from or in connection with the loss of the use of the residential fire sprinkler system on the
Property during Customer’s ownership of the Property. CVWD shall make all decisions with respect to its
representation in any legal proceeding concerning this section. Customer hereby waives all claims and demands
against CVWD for any such Costs.
Customer acknowledges that CVWD shall have no obligation nor responsibility with respect to the design,
construction, testing (including inspection to ensure that such system is operational), operation, maintenance, repair
or replacement of the residential fire sprinkler system on Customer’s Property which shall be Customer’s
responsibility and Customer shall bear all risk of loss or damage thereto and/or thereby, by whatever cause inflicted
which shall be Customer’s responsibility.
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