Fillable Printable Sample Form for Fire Service Application
Fillable Printable Sample Form for Fire Service Application
Sample Form for Fire Service Application
ACCOUNT NAME: ____________________________________________________________________________________________________
ACCOUNT ADDRESS: _________________________________________________________________________________________________
MAILING ADDRESS (IF DIFFERENT FROM ACCOUNT ADDRESS): ______________________________________________________
PROPERTY OWNER: __________________________________________________________________________________________________
PROPERTY TENANT: __________________________________________________________________________________________________
CONTACT PERSON: ___________________________________________ TELEPHONE NUMBER: _______________________________
TYPE OF ACCOUNT: □ RESIDENTIAL □ COMMERCIAL
□ INDUSTRIAL □ OTHER (SPECIFY): ___________________________________________________
PROPERTY NUMBER: __________________________________________ BUILDING PERMIT NO.: ______________________________
SERVICE LINE SIZE: ____________________________________________ EST. MAX DAILY CONSUMPTION: ____________________
DATE SERVICE REQUIRED: ____________________________________________________________________________________________
NEW CONTRUCTION: □ YES □ NO OWNERSHIP TRANSFER: □ YES □ NO
By signing this Application, the applicant agrees to abide by the Rules and Regulations of Capital Region Water, in
particular the provisions governing the terms and conditions of the furnishing of private fire protection service. In
addition, the applicant agrees to submit a new application for approval prior to making any changes, alterations,
additions or deletions to the fire protection system covered by this application.
_________________________________ ______________________________________________________
DATE SIGNATURE OF APPLICANT
APPLICATION MUST BE SUBMITTED AT LEAST 30 DAYS PRIOR TO THE REQUESTED INSTALLATION DATE. TWO (2) SETS
OF DETAILED PLANS MUST ACCOMPANY THIS APPLICATION FOR REVIEW BY CAPITAL REGION WATER. FAILURE TO DO
SO WILL RESULT IN THE REJECTION OF THE APPLICATION.
INSPECTION DATE: ____________________________________________ INSPECTOR: __________________________________________
MAIN SIZE: __________________________ METER SIZE: ____________________ METER NUMBER: ____________________________
TAP SIZE: ____________________________ METER MAKE: ___________________ METER READING: ____________________________
TYPE (MATERIAL) OF SERVICE: ________________________________________________________________________________________
LOCATION OF SERVICE: ______________________________________________________________________________________________
CURB BOX TO GRADE: □ YES □ NO
CURB BOX ACCESSIBLE: □ YES □ NO
VALVE ON CURB SIDE OF METER: □ YES □ NO TYPE: ________________________________________
BACKFLOW PREVENTER INSTALLED: □ YES □ NO
PLEASE COMPLETE AND RETURN TO:
CAPITAL REGION WATER
212 LOCUST STREET, SUITE 302
HARRISBURG, PA 17101
717-525-7677
FIRE SERVICE APPLICATION
CAPITAL REGION WATER USE ONLY
