Construction Request

Customer's Information

Contact Information:

Contact Role *This question is required.

Last Name *This question is required.

First Name *This question is required.

Middle Name

Company *This question is required.

Daytime Phone *This question is required.

Cell Phone

Fax

Email *This question is required. This question requires a valid email address.

Mailing Address *This question is required.

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Project Location

Site Address *This question is required.

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Legal Description

Lot Number

Block Number

City/Township Name

Parcel

Contractor Information

General Contractor

Phone Number

Contact Person

Electrical Contractor

Phone Number

Contact Person

Architect-A&E Firm

Phone Number

Contact Person

Mechanical Contractor

Phone Number

Contact Person

Billing Information - Entity responsible to pay for utility usage AFTER construction (permanent service)

Existing Account Number *This question is required. This question requires a valid number format.

Company

Business Type

Doing Business As (DBA) Name

Billing Address

City

Zip Code

Primary Phone

Daytime Phone

Cell Phone

Fax

Email This question requires a valid email address.

Tax Exempt?

If yes, send copy of S-211 Exemption

File: {{filename}} delete

Authorization for Service (NOTE: Signature also required on Underground Damage Liability Waiver page)

Signature *This question is required.

Date *This question is required.

Printed name *This question is required.

Construction Request - Commercial