Water Service Application Form

CHIMNEY ROCK VILLAGE APPLICATION FOR WATER SERVICE           Amount Paid _________  Cash or Check # _________ Date Paid __________           Approved: ___________  Rejected: ___________    (see attached explanation)           Signature of approving Chimney Rock Village and Lake Lure Officials:           Chimney Rock Official: ____________________________ Date: __________           Lake Lure Official: ________________________________ Date: __________

1.         Name of owner(s) as appearing on title/deed:

            __________________________________________________________________                                     

2.         Location of property: ________________________________________________

            __________________________________________________________________

3.         Property Tax Pin: ___________________ Map ­­______ Block ______ Lot _____

4.         Owner(s) mailing address: ____________________________________________

            __________________________________________________________________

5.         Signature of Owner(s): _______________________________________________

            __________________________________________________________________

6.         The Dwelling or Building applying for water service contains the following:                                          

            Note:   Each water tap is for water service to one lot, or dwelling / building only. 

            Water service connections may not be shared.  Violators will be disconnected.

            Number of:      bathrooms __________          bedrooms _________                        

            Does this property have a swimming pool? __________________                                      

            Private Residence or Commercial / Business: _____________________________

Chimney Rock Application for Water Service cont.

            If commercial / business, state name and type of business ___________________

            __________________________________________________________________

7.         Person making application: ___________________________________________

            Relationship to owner (contractor, etc.): _________________________________

            If not owner, reliable contact phone number ______________________________

8.         Water account billing information:

            Name of account holder: _____________________________________________

            Billing address: ____________________________________________________

            _________________________________________________________________

            Phone number(s): ___________________________________________________

            __________________________________________________________________

            In accordance with the Identity Theft Program, account holders are required to       show two forms of identification in person, one being a photo I.D. (Drivers        License, Social Security Card, Voters Registration, Passport, etc)

            Identification #1 ____________________________________________________

            Identification #2 ____________________________________________________

Note: Water service fees shall commence billing the date the water meter is installed

WATER TAP FEES:           ¾” - $1, 000                1” - $2,000                  2” - $3,000

9.         Signature of applicant/responsible person who has read and understands the above            information and verifies that all information given on this application is correct.

            _____________________________________________ Date ________________