HomeMy WebLinkAboutIMAGE 3 - 22-00482 - Western Mountain Inc. FHM 25�s
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Jr. Legal Pad 63107
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FARE HYDRANT USE PERMIT •zaar as
NONTRADITIONAL WATER CUSTOMERS-
35 rl.r% ss East croon
Ronemeon®re.b�r-
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Wake issued Z,
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REXBURG
Meter
Lia f t'1 Permit #- HOse Number._
Business name. UL atrw I J
^ Phone #
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Phone #
Address.
Year Issued:
Deposit amt'. (Receipt Code= W[ P) with credit cards charge an additional 3.5`% (Receipt Code= MISCG)
$1,800 - 2" Water Meter t/
$ 800 - 1" Water Meter Deposit retained? or refunded?
CONDITIONS OF PERMIT: ( date)
In order to prevent possible co
desiring to obtain water from burg city water system, any persons or entity
1. Obtain a written per *following:
2Take water on] "pirforc attempting to take any water.
. y fr vdranr
enng device from the to the fire hydrant
he city water deptm
will be required on a
r any use, repair,
r. (City water d
' gh the metering
Fee: 1 Ea 1 /QQj
6. A $50.00 maintena 2" will be assessed each year for t/ i
maintenance on the
The meter needs to be ..orations. A meter can be reissued the same da
request if needed. y per
Any person or entity not complying with this policy shall be assessed a penalty charge of $400 in addition
to the normal charge for the water taken.
of Applicant
REFUND TO
METER OK: YES _ OUT READs,�' �r {� CHARGES:
NO IN READ METER MAINT 75.00
GAL USED 0- 1000 GAL 10.00
READ DATE ADDITIONAL WATER
METER RE -ISSUED? YES/ NO REPAIRS -PARTS
TOTAL
issued by: Received by:
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1 certify trader pmwty os
knowledge sed belief 1 cattily OL_
I also hereby authorize and direct
pruressional Licenses or its authl res
that may hale bearing on my ehgtbt
Occupational and professional License%
othcmlw he protected or t.onGdential .
appitution
State of , County of
Subscribed and sworn before me this
(seal)
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Note: The applicant's signature must be notarized. The applicants must declare the ads..
notary ouratt. The language "subscribed and sworn" must appear before the applicant's signal".
"acknowledgement" where the notary only verifies the identity of the applicant is not acceptable.
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