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2. I, *
4. release the Town of Firestone from any liability for turning the water service back on at
6. Service Address*
8. Phone Number*

10. I understand that by not being present at the time that service is reconnected at the above address that I am not able to check for any open water faucets, water spigots or pipe damage that may exist in this home and that if there is open water faucets, water spigots or damage to the pipes at this address the Town of Firestone is not liable for any water loss or damage that may be caused by turning this service on. I also understand that this service will not be turned on immediately, but will be turned on sometime before the end of the business day.

12. Check Here*

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
14. Signature*
15. Date*
17. NOTICE

    The Town of Firestone will turn the water on at the meter pit. If the water meter continues to spin after the system is pressured up the town will shut the water back off and an appointment will need to be made by the above signer to meet the town at the service address. This appointment will need to be made 24 hours in advance. This form can only be used if water has been shut off for non-payment within the last 48 hours.

    By paying with a check and signing this application, you authorize the Town of Firestone to make a one-time electronic debit from your bank or asset account for the amount of the check. For inquiries, please call 303-833-3291.

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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit Submit and Print

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