Water & Sewer Fee Determination Form - City of Martinsville, Indiana

Applicant Name (entity requesting service)*

Phone*

Address of Applicant*

Street Address Address Line 2 City State ZIP Code

Address of Property to be served*

Street Address Address Line 2 City State ZIP Code

Zoning Classification

Inside Martinsville City Limits*

Yes
No

Single-family or two-family, dwelling 5/8" meter requested*

Yes
No

Describe Use

including but not limited to: retail sales; general office; restaurant, including fast or carry out foods; grocery; convenient store; gasoline station; professional office, doctor, dentist, clinic, hospital or nursing home; barber or beauty shop; service club, church, civic or fraternal organization; school, college, daycare or library; stage or movie theater; hotel, motel, apartments (more than four units); assisted living or retirement center; car wash; self service laundry; correctional facility, jail or prison; industrial, manufacturing, warehousing; service or repair, dry cleaners, body shop, engine repair, brake/muffler, computer, electronics, contractors, or appliances; recreational facility, picnic areas, campground, racetrack, sport park, open-air stage. IF MULTIPLE USE DESCRIBE ALL USES.

Number of fire hydrants on private property

Number of restrooms

Size of water meter requested

If fire service connection required circle size

4"
6"
8"

Automatic Sprinklers

Yes
No

Kitchen facilities

Yes
No

A bar or bar area

Yes
No

Showers or shower facilities

Yes
No

Seating capacity for restaurant, theater, church, service club

Number of chairs, beds, exam tables

(barber, beauty, doctor, dentist, clinic, hospital)

Total Number of employees, students, children, teachers, residents, avg. attendance

(race track, sport park, open-air stage)

Number of

rooms (hotel/motel), bays (car wash), machines (laundry), car spaces (drive-in restaurant), inmates (jail or prison), visitors (picnic area, fairgrounds), campsites (campground)

Number of parking spaces

Hours of operation

Number of shifts

Building area (square feet)

for (retail sales, occupied space (excluding storage))

Restaurant area (square feet)

Other use area

(list use under remarks)

Remarks