Only fill out this form if you meet the following requirements:

• You are the applicant, and you own the property (it may be tenant occupied)
• The property is residential, or if mixed-use, it is primarily residential
• The property does not contain more than four units
• The property received a Notice of Defect for a repair required on the property’s water service pipe or sewer lateral, and/or related components
• The payment agreements (if applicable) for the property are current

• The property is served by an operable water meter
• Applicant is not delinquent on their monthly water bill(s) for more than 2 cycles, for the property with the Notice of Defect and other properties owned by the applicant
• You consent to the placement of a lien on the property for the amount of the total cost of the work

---

FOR LEAD SERVICE LINE REPLACEMENT ONLY:

• The property has a confirmed lead service line

Confirm the presence of lead by performing a lead test at home, or consulting with a registered plumber, or by notification via a Water Department inspector