HomeMy WebLinkAboutCity of Glenwood Springs Electric and Water Application.ergs Electric & Water System
::-esth St, Glenwood Springs, CO 81601
Oate of Application
Applicant's Name:
Service Address:
Mailing Address: 7
City: State: ( r Zip: t
•r.
Email Address: ►4 , 4
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Electric & Water Service & credit Application
PH. 970-384-6400 FX.970-945-2597
OFFICE USE ONLY
Deposit Number
Deposit Amount
Deposit Date
Cell- 1 G ,
Work: _ ( , r 7 Home
Have you previously received electric service from Glenwood Springs Electric? Yes No _ t
If Yes, please provide location and date of service:
Owner Name:
Employer: r ! r
Address:
City State Zip
Length of Employment:
Soc. Sec. No. ! e'
Or Bus. License No.
Optional:
Third party notification, or person to contact in case of
emergency or disconnect notification: (Third party must not
live in same location and must sign this form)
Name:
Address:
City
state:
Zip
DL# f f r ! �. i (t Phone:
Name on ID: i Signature:
i
I understand that electric anergy will be provided in accordance with the most current rules and regulations of the City of Glenwood Springs Electric and Water System. The rules and regulations are availabie for review
at the office of the utility board or the City aark's office . I hereby agree to pay promptly for the service fw which I am bitted and further agree that my $@mks may be terminated after notice of failure to make such
timely payments. I also understand that service may be disconnected and I may be liable to criminal proceedings for tampering with the meter measuring my ssrvice or far theft of electric energy or water Also 1 under-
stand that I will be requires to pay a reconnect fee and possible additional utility deposits before service is reconnected and that on mferrsl of my account forcollectlon, I will be liable for payment of all reasonable
costs, Including court costs and attorney fess.
Signature: ` f / L� •. _-'� I Date:
c�
BUILDING DEPARTMENT FEES PAYMENT AREEMENT
THIS AGREEMENT is made and entered into by and between the City o Glenwood Springs, Colorado a
municipal corporation (hereinafter "City"), and F16--k'T
(Hereinafter "customer") whose address is f and soci security number is
2.
3.
4.
to be effective the ',""L day of 0 67.6,5 2014.
RECITALS:
A. Customer owes the following amount on the final Sewer System Improvement Fees.
B. Customer has received a notice these fees are due in order to connect to the system.
Fees Due. Owner acknowledges the obligation to pay the following fees to the City of Glenwood
Springs for 1573 CR 154, GIenwood Springs, Colorado.
Sewer Improvement Fee $ 7,163.91
Total $ 7,163.91
INSTALLMENT PAYMENTS. Customer agrees to pay the
Date: QC 1 �'{ 2A1
Date: Alecl, 2, crI of
Date: Pigg- 2-01 V
Date: Jeu, a O!S-
Date: 2a es -
Date: )VU,, 2plS'
Amount to be paid:
Amount to be paid:
Amount to be paid:
Amount to be paid:.
Amount to be paid:_
Amount to be paid:_
foregoing amount as follows.
$ 1,193.91 J
—4a—
_$ 1,194.00
$ 1,194.00
$ 1,194.00
$ 1,194.00
$1,194.00
IF ANY installment is not paid in full with good funds, when due, as listed above, the unpaid balance
shall be due and payable without any further notice by the City. The City shall turn the account over to
the City's current collection agency for COLLECTIONS and THE CITY MAY EXERCISE ITS
OPTION TO PLACE A LIEN ON THE PROPERTY UNTIL PAID.
If the person signing this agreement is other than the name on the account, they are assuming financial
responsibility for the above mentioned account and will be sent to collections if account is not paid
according to this agreement.
City ofGl nwo d pangs
Customer Signature
R-� L,1 Phone #
Customer Name Printed