CITY OF CLERMONT
UTILITY SERVICE REQUEST FORM
Date of Request: ______________, 20___ Date of Service:_________________
Customer Name:______________________________________________________________
Phone Number:__________________________________________
Mailing Address:
.
City: State: Zip: .
Service Address:_________________________________________
City:
State: Zip: .
Lot #:_________________________ Phase:______________________
Subdivision:__________________________________________________________________
Owner Name:_________________________________________________________________
Mailing Address:
.
City: State: Zip: .
Forwarding Address:_____________________________________________________
City:
State: Zip: .
Check one: Commercial_____ Single Family_____ Multi-Family and # of Units_______
Meter Tampering Fee A fee of $50.00 per incident shall be charged to the
Individual responsible for payment of the utility account.
City staff completes this section
Service Requested:____________________________________________________________
Size:__________________
Water Meter: ___________________
Irrigation Meter:_________________
Meter Reading:_____________ Meter Serial #:______________ Manuf.:______________
Date of Service:______________
Comments:___________________________________________________________________
____________________________________________________________________________
\\Cityhall\shares\Planning and Zoning\Applications\Utility Service Request Form 2-1-13.doc
City of Clermont
Planning & Zoning Department
685 W. Montrose St.
P.O. Box 120219
Clermont, FL. 34712-0219
(352) 394-4083 Fax: (352) 394-3542
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