Fireline Application

Fireline Application
FORM

Fireline Application
NOTE: * indicates a required field
Fireline Size
Service Address:*
Lot No
Tract or Block
APN*
(From your property tax records)
Customer Information
Property Owner Name (as it appears on title):*
Shareholder
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone
Business Phone
E-mail*
Will a commercial tenant BE responsible for the fire line charges?

YESNO

Commercial Tenant Information
Name of Business:*
Business Owner Name:*
Tenant Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Tenant Cell Phone
Tenant Business Phone
Tenant E-mail*
example@example.com

Terms & Conditions
I hereby apply for fire lineservice for the above-referenced property. I understand that this application is subject to approval by AMWC. I agree to use the fire line and pay all rates and charges for the fire line in accordance with the rates, rules, and regulations of AMWC.

I understand and agree that AMWC will make all connections to the existing water main and install the fire line from the water main edge of right-of-way ro back of sidewalk. I understand and agree that AMWC will provide me with an estimate for the installation work and agree to pay a deposit for the work before the fire line is installed. I understand and agree that that AMWC will bill me or reimburse me for the difference between the deposit amount and the actual cost incurred by AMWC to install the fire line.

I understand and agree that AMWC's maintenance responsibility for the fire line ends at the tapping valve to install the fire line.

I represent and warrant that I am authorized to sign this application and agree to defend, indemnify, and hold Atascadero Mutual Water Company harmless from and against any and all claims, actions, demands, liabilities, damages, settlements, costs, fees and expenses, including reasonable attorney and expert witness fees and expenses, arising out of or related to any breach or claimed breach of this representation and warranty.
Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature, or any resulting agreement between you and AMWC. In addition, you are confirming that you are the shareholder authorized to enter into this Agreement.
I Accept*

By checking this box and typing my name below, I agree to the terms and conditions of the Electronic Signature Agreement, and I am electronically signing my application.
Signature*
First Name, Middle Initial, Last Name
Date*

MonthDayYear
Date
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