Water Service Application

1. I hereby make application to the Centerville-Osterville-Marstons Mills Fire District, Water Department (the "Department") for water service at Lot Number. shown on Land Court Plan No. or on plan recorded in Barnstable County Registry of Deeds at Book , Page , being house number , Street , in the village of , and shown as Barnstable Assessor's Map & Parcel # .

2. By the execution hereof, the undersigned represents and warrants that he has read and understands, and agrees for himself, his heirs, successors and assigns to abide by, the Rules and Regulations of the Water Department as in effect from time to time.

3. No applications shall be made seeking any installation in violation of any law, rule or regulation, including the state building and state and local health codes, and without limiting the generality of the foregoing, no connections will be made to water services lines located within 10 feet of electric, telephone, cable or gas lines or to water service lines, which pass under electric, telephone or gas lines.

4. The undersigned acknowledges, understands and agrees that the Centerville-Osterville-Marstons Mills Fire District, including the Water Department, and its and their agents, servants and employees (herein the "District") do not undertake, in connection with the provision of services requested herewith or otherwise, to survey the premises above or below ground to ascertain the location of any underground obstacles, including underground electric, telephone, gas, cable, private water, septic system or other subsurface installation or private line; and furthermore, the undersigned warrants and represents that he/she has exercised due diligence in compiling the sketch referred to in Paragraph 6, below.

5. The undersigned herewith and hereby releases and agrees to indemnify and hold harmless the Centerville-Osterville-Marstons Mills Fire District, its Water Department and its and their agents, servants and employees of and from all loss, costs, claims, demands, actions, causes of action and assertions or right or remedy, whether legal or equitable and in whatever court of forum, arising or claimed to have arisen from or in connection with work, labor or materials provided by or at the request, direction or behest of the Centerville-Osterville-Marstons Mills Fire District and/or Water Department thereof for the delivery of water service to the premises described above, except to the extent such are the result of the gross negligence or willful conduct of the said District.

6. Building permit, certified plot plan, sewage disposal plan and copy of owner's title deed as recorded or filed must be submitted with application for new construction. Service bills are charged for materials, labor and MA sales tax. Patch, road opening permit and detail officer are also charged as necessary. Service bills must be paid before water service is activated. Existing homes please sketch on the reverse side the precise location of where water line is to be installed; new construction submit sketch based on certified plot plan, showing existing or intended underground features.

Name of Owner Per Deed

Title Reference

Present Address

Future Billing Address

Phone

Cell Phone

Meter Size: , Line Size:

Systems Development Charge

Witness my/our hand(s) and seal(s) this day of ,20

Owner

By typing your name below this serves as your legal Signature

Date SDC Paid

Check Number