Application For Water Service (Page 3 of 4) in pdf

Application For Water Service Page 3

Owner’s written permission for tenant to have water service at this address.

(Failure by the owner to approve and return this form, within 10 days, will result in

termination of service until form has been received by the Water Division)

I/we, the undersigned owner(s) of the property listed on this application agree to water service being

initiated as requested. I/we further acknowledge that water bills not paid by the applicant are my/our

responsibility and I/we agree to pay those water bills and any other charges incidental to terminating

service for non-payment. I/we also acknowledge that payment delinquency can result in the property being

ineligible for the Service Line Insurance Program should a leak occur.

I/we acknowledge as owner(s) that even if the property listed below is covered by the Service Line

Insurance Program, any water damage or other consequence of a leaking service line or any property or

personal injury resulting from my service line, stop box, curb stop (t-head) or other water appurtenance or

any associated depression or holes are my/our responsibility and I/we do not hold the City of St. Louis

Water Division liable.

I/we, the property owner(s) of the service address listed below agree to the terms and conditions of the City

of St. Louis Water Division.

SERVICE ADDRESS

ZIPCODE

Signature of Property Owner(s): _______________________________________

Date: ________

PROPERTY OWNER NAME

MAILING ADDRESS

CITY

STATE

ZIPCODE

TELEPHONE NUMBER

(

)

The owner of this property must sign and return this application within 10 days to:

Water Division Customer Service

1640 S. Kingshighway Blvd.

St. Louis, MO 63110

(Form CS1 – 04/2013)

Application For Water Service Page 3