City of UplandResidential Utility Services Application

Applicant Information:

Applicant Name*

Secondary Applicant Name

Service Address:

Service Address*

City*

State*

Zip Code*

Mailing Address:

Mailing Address*

City*

State*

Zip Code*

Phone Number:

Phone Number*

Phone Type

Alternate Phone Number

Phone Type

Email Address:

Email Address*

Security Information:

Social Security Number*

Federal Tax ID

Driver License:

Driver License Number

Driver License State

Date of Birth

Attestations:

Do you have an active business license at this property? Multi Family Dwellings (3 or more units) and commercial properties are required to have a business license with the City of Upland.

Yes

No

Do you have an active alarm system at this property? If you choose to install an alarm system at a later date, you attest that you will obtain a permit for a fee of $78.00 with the City of Upland.

Yes

No

Do you have a dog(s) at this property? If yes, you attest that you are aware that a dog 4 months of age or older must be licensed through the City of Upland within 30 days, and a current rabies certificate must be provided to obtain a license.

Yes

No

I understand that trash service is provided by Burrtec Waste and will be billed separately. To establish service, I will contact Burrtec at (909) 949-0500.

Photo ID:

Please provide at least one form of photo ID. (Acceptable file formats: JPG, PDF, or PNG)

Driver's License

Proof of Ownership:

Please provide a Final Settlement Statement or Recorded Grant Deed. (Acceptable file formats: JPG, PDF, or PNG)

Final Settlement Statement

Trustee Information:

If the property ownership is listed as a Trust: Please provide a copy of the trust documents that names the party attempting to establish service as a Trustor/Trustee. (Acceptable file formats: JPG, PDF, or PNG)

Trust Documents

Business Information:

If the property ownership is listed as a Business Name: Please provide copies of the Articles of Incorporation/LLC/LP documentation that names the party attempting to establish service as an authorized agent for service. (Acceptable file formats: JPG, PDF, or PNG)

Business Documents

Service Dates:

Service Start Date*

If it is not possible for me to be present at the time the water service is to be connected, I will assume responsibility for any water damage caused as a result of this turn-on.

To request service disconnection, please contact Customer Service at 909-931-4150

*Same Day Service Fees: $75.00 (before 4:30PM) / $150.00 (after 4:30PM)

Signature:

I agree to use water and sewer utility services and pay therefore in accordance with the rates, and regulations legally in effect by the City of Upland. I declare under penalty of perjury under the laws of the State of California that the information that I have provided is true and accurate. I acknowledge that the provision of false information is grounds for termination of service. By entering my name below, I confirm my agreement and acceptance of the terms of this application and authorize the requested service.

Signature*

Signature Date*

Finance

Residential Utility Services Application