Water/Sewer
Availability Request
280 Madison Avenue N | Bainbridge Island, Washington 98110 | www.bainbridgewa.gov
Page 1 of 5
Previously received non-binding commitment? Water Sewer
Previously Received binding commitment? Water Sewer
Previous case number(s): _____________________________
Has information changed since previous submittals? Yes No
Date Received: _______________ Case Number: _______________
Application Purpose:
Water
Information
Non-binding Commitment
1
Binding Commitment Limited Reservation
2
Binding Commitment Unlimited Reservation
3
Approval to Connect
Sewer
Information
Non-binding Commitment
1
Binding Commitment Limited Reservation
2
Binding Commitment Unlimited Reservation
3
Approval to Connect
Project Information:
Project Name: ____________________________________________________________________________________
Project Description: _______________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Parcel Number(s): _________________________________________________________________________________
Site Address: _____________________________________________________________Bainbridge Island, WA 98110
Current Use: Single Family Residence Multi-Family Residences Commercial/Industrial Vacant Land ADU
Is this an LID area? Yes No Don’t Know Subject to Latecomer’s Agreement? Yes No Don’t Know
Forecasted Connection Date? (MM/YY) Water _____ /_____ Sewer _____ /_____
Applicant Information:
Owner
Name: __________________________________________ Existing COBI Utility Account Number(s):
Address: _________________________________________ _____________ _____________ _____________
________________________________________________
Phone: ____________________________________ Email: ___________________________________________
Agent
Please attach notarized Owner/Applicant Agreement Form
Name: ___________________________________________ Agency: ___________________________________
Address: _________________________________________
_________________________________________________
Phone: _____________________________________Email: ___________________________________________
Water/Sewer
Availability Request
280 Madison Avenue N | Bainbridge Island, Washington 98110 | www.bainbridgewa.gov
Page 2 of 5
Current Connection Information:
Current Connections: Water Sewer Separate fire protection water main tap Septic Well None
System: COBI Winslow COBI Rockaway Beach KCSD 7 KPUD Private Don’t Know
Type(s): Single Family Residence Multi-Family Residences Commercial/Industrial Irrigation ADU
Commercial/Industrial Use type: ____________________________________________________________________
Number of Buildings: ______ Total Units: ______ Meter Size(s): ____________ Backflow Prevention: Yes No
Number of connected ERUs: __________ Apply credit from existing use: Yes No
Existing Account Number(s): _____________ _____________ _____________ _____________ _____________
Proposed Connection Information:
Water
System: COBI Winslow COBI Rockaway Beach KPUD Well Don’t Know None
Type(s): Single Family Residence Multi-Family Residences Commercial/Industrial Irrigation ADU
Commercial/Industrial Use type: _________________________________________________________________
Number of Buildings: ________ Units/Building: ________ Total Units: ________ Number of Meters: _______
Meter Size: _______ _______ _______ _______ Backflow Prevention Required? Yes No Don’t Know
Separate fire protection water main tap Yes No
Sewer
System: COBI Winslow COBI Rockaway Beach KCSD 7 Septic Don’t Know None
Type(s): Single Family Residence Multi-Family Residences ADU Commercial Industrial (see below)
Commercial/Industrial Use type: ________________________________________________________________
Total Number of Connections: __________ Total Number of ERUs: __________ (From attached table)
Multi-Family Residential Units
Bldg./Unit
# _____
Bldg/Unit
# _____
Bldg/Unit
# _____
Bldg/Unit
# _____
Dwelling units per building:
___________
___________
___________
___________
Total Units____________
Water/Sewer
Availability Request
280 Madison Avenue N | Bainbridge Island, Washington 98110 | www.bainbridgewa.gov
Page 3 of 5
Fixture Type
Fixture
Unit
Value
Current
Bldg/Unit
# _____
Bldg/Unit
# _____
Bldg/Unit
# _____
Bldg/Unit
# _____
Total
QTY
Fixture
Units
QTY
Fixture
Units
QTY
Fixture
Units
QTY
Fixture
Units
QTY
Fixture
Units
QTY
Fixture
Units
Bath tub and/or shower
4
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Dental units or lavatory
1
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Dishwasher, commercial
4
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Drinking fountain heads
1
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Hose bib or sill cock
5
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Laundry tub or clothes washer
4
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Sink: bar or lavatory
2
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Sink: clinic, flushing
10
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Sink: kitchen
4
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Sink: other
4
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Sink: wash, circle spray
4
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Urinal: flush tank
3
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Urinal: pedestal
10
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Urinal: wall or stall
5
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Water closet, tank
5
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Water closet, flush valve
10
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Other: _____________________
____
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Total Fixture Units:
__________
__________
__________
__________
__________
__________
Total ERUs:
_______
_______
_______
_______
_______
_______
Fixture Unit Value X Quantity = Fixture Units
20 Fixture Units = 1.0 Equivalent Residential Units (ERU) rounded to the nearest 1/100 ERU
The discharge of industrial wastewater (other than domestic wastewater) into municipal sewerage systems which could
interfere with, pass through, or otherwise be incompatible with such systems or which would contaminate the sludge will
not be permitted. WAC 173-216
Will industrial or commercial wastewater (other than domestic wastewater) including
wastewater from restaurants, food processing facilities, and chemical processing facilities be
discharged into the City of Bainbridge Island’s (City) wastewater treatment plant?
_ Yes _ No
Will industrial or commercial wastewater (other than domestic wastewater) including
wastewater from restaurants, food processing facilities, and chemical processing facilities be
discharged into the Kitsap County Sewer District 7 (SD7) wastewater treatment plant?
_ Yes _ No
Applicants submitting a request for sewer connections where industrial or commercial wastewater (other than domestic
wastewater) will be discharged in the City or SD7 wastewater treatment plants shall provide engineering data in a form
determined by the City Engineer or designated representative to establish pretreatment requirements.
Water/Sewer
Availability Request
280 Madison Avenue N | Bainbridge Island, Washington 98110 | www.bainbridgewa.gov
Page 4 of 5
Additional Submittal Requirements:
Site Plan: Must include existing and proposed water and sewer mains, lines, connections, and meters with
proposed development. The site plan must be legible, easily understood, and in a recognized scale. Information and
sample site plans are available in the Administrative Manual for Planning Permits:
http://www.bainbridgewa.gov/DocumentCenter/View/100.
Other specifications or engineering as required.
Application Notes and Information:
1
A ‘non-binding commitment for water or sewer system availability’ means the City currently has available water or
sewer system capacity but does not guarantee the future availability of water or sewer system capacity.
2
A ‘binding commitment for a limited reservation of water or sewer system capacity’ means that, upon payment of a
non-refundable deposit on system participation fees pursuant to BIMC 13.16.040, the City shall reserve water or
sewer system capacity, and shall allow connection to the City’s water or sewer system, for a period not to exceed
four (4) years from the issuance date of an approved binding commitment letter subject to the requirements
stipulated in the binding commitment letter.
3
A ‘binding commitment for an unlimited reservation of water or sewer system capacity’ means that, upon payment
of all applicable system participation fees set forth in BIMC 13.16.040, the City shall reserve water or sewer system
capacity, and shall allow connection to the City’s water or sewer system, in perpetuity subject to the requirements
stipulated in the binding commitment letter.
When the City of Bainbridge Island issues a binding commitment for water or sewer system capacity, and service main
extensions or other capital facility improvements are not required, the City of Bainbridge Island shall provide water
and/or sewer service pursuant to the requirements and conditions stated in the binding commitment letter. When
the City of Bainbridge Island issues a binding commitment for water or sewer system capacity, and service main
extensions or other capital facility improvements are required, the owner shall enter into a Utility Extension
Agreement with the City of Bainbridge Island at their own expense pursuant to the requirements and conditions
stated in the binding commitment letter, and BIMC 13.32.
Applicants desiring a building or tenant improvement permit, or water service to an accessory dwelling unit (ADU) are
required by Kitsap County Health District to submit a binding water availability letter and a binding sewer availability
letter stating that the public water system will supply potable water. These letters are provided at the time a binding
commitment is issued.
At the time of payment of fees and the receipt of a binding commitment, the owner is acknowledging and agreeing to
comply with all codified regulations and rules now in existence or which may be established from time to time by the
City of Bainbridge Island governing the operations of its public water and sewer systems. The owner specifically
agrees to install all plumbing systems in accordance with the conditions stated in the binding agreement and maintain
at all times their plumbing system(s) in compliance BIMC15.04 and the City of Bainbridge Island Design and
Construction Standards and Specifications as they pertain to the prevention of water contamination, prevention of
pressure surges, and thermal expansion in their water and sewer piping. Further, the applicant agrees at the time of
final payment and receipt of a binding agreement for connection not to make a claim for damages against the City of
Bainbridge Island or its agents or employees for damages and/or loss of production or sales or service caused by the
disruption of water or sewer service for system repair, routine maintenance, power outages, and other conditions
normally expected in the operation of a water or sewer utility.
Water/Sewer
Availability Request
280 Madison Avenue N | Bainbridge Island, Washington 98110 | www.bainbridgewa.gov
Page 5 of 5
Should an agent submit an application, a notarized Owner/Applicant Agreement must accompany the application.
http://www.bainbridgewa.gov/DocumentCenter/View/167
I affirm, under penalty of perjury, that all answers, statements, and information submitted with this application are
correct and accurate to the best of my knowledge at the time of submittal. I also affirm that I am the owner or
designated agent of the subject site. Further, I grant permission to any and all employees and representatives of the City
of Bainbridge Island and other governmental agencies to enter upon and inspect said property as reasonably necessary
to process this application. I agree to inform the City of any and all changes in the information submitted, and to any
change in use with the resubmittal of this form prior to final payment of fees and connection to the City’s water or
sewer systems.
Print Name (Owner) Signature (Owner) Date
Print Name (Owner) Signature (Owner) Date
Print Name (Owner) Signature (Owner) Date
Print Name (Owner) Signature (Owner) Date
Print Name (Agent) Signature (Agent) Date