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 □NOOWNERSHIP 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 anew 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 PRIORTO THE REQUESTED INSTALLATION DATE. TWO(2) SETS
OF DETAILED PLANS MUST ACCOMPANY THIS APPLICATION FOR REVIEW BY CAPITAL REGION WATER. FAILURETO 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
