Lot:
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Block:
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Subdivision Name: (or N/A)
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Service Address:
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Town:
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State:
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Zip Code:
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Customer Name:
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Current Mailing Address:
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Mailing Town:
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State:
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Zip Code:
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Builder Name:
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Residence Area Code and Telephone Number:
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Business Area Code and Telephone Number:
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Ext.
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Builder Headquarters Address:
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Town:
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State:
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Zip:
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Builder Email:
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Jobsite Area Code and Telephone:
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Service Township:
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Service County:
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Builder Fax Area Code and Number:
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Proposed Meter Location:
Meter location cannot be more than five (5)
feet beyond the front. Location must be marked on foundation w/paint or
stake "G" for gas.
As you face the house from the street:
Front
Right
Left
Vehicular Traffic:
The Illinois Commerce Commission mandates that
meters installed within three feet of vehicular activity are protected
by a concrete guardrail. The cost of the guardrail's installation is $350.
If your meter is within three feet of vehicular traffic, you will be
contacted by a Gas Construction Consultant to arrange a site visit to
evaluate the property.
Is the proposed meter location within 3 feet of
vehicular traffic (driveway, roadway, parking lot, alley, etc)?
No
Yes
Proposed Appliances:
Range
Water Heater
Gas Heat
Gas Dryer
Other
What is the total square footage of the home?
Will Your Gas Load Requirements Exceed 300,000 BTUs?
No
Yes
If yes, Total BTU's:
Septic Field:
No
Yes
If yes, send plan.
Location:
Front
Back
Right
Left
Type of Construction:
Single Family
Condo
Townhome
Duplex
Mobile Home
Stage of Construction:
No foundation
Foundation Backfill Date
Foundation
Shell
Under roof
Drywall
Existing
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Winter Construction Costs: Nicor Gas may encounter winter construction conditions during the period from November 15 through
March 15 that increase installation costs. You are responsible for the estimated fully distributed cost of the incremental
activities required for installation under winter construction conditions. Do you request that Nicor Gas install service
between November 15 and March 15, provided that Nicor Gas gives you a prior estimate of the increased costs?
Yes
No
Date Service is Required:
Remarks:
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Approximately how far is the building/house
from the road?
What is the name of the
nearest cross street?
What direction are you
from that street?
N
S
E
W
Within City Limits?
No
Yes
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Owner acknowledges inability
to provide a plat or other indication of possible underground facilities
including but not limited to septic, water, electric or telephone lines.
In consideration for the placement of the gas service piping without such
plat of other indication, Owner shall indemnify, defend and hold harmless
Nicor Gas, its employees, agents and contractors from and against any
and all suits, actions, claims and damages, interest, attorney fees, costs
and expenses of whatsoever kind or nature whether arising before or after
completion of the work thereunder and in any manner directly or indirectly
caused, occasioned or contributed to in whole or in part by reason of
any action, omission, fault or negligence of the Owner, including by not
limited to the omission to provide the plat or other indication. Owner
is responsible for repair and restoration on private property. Nicor Gas
is responsible for public restoration only, and will not be held liable
for any damage to any trees located on the above-mentioned property.
Nicor Gas is requested to install gas service pipe at the above service
address under the Rates, Riders, and Terms and Conditions of the company
on file from time to time with the Illinois Commerce Commission, including
Rider 4-Gas Service Pipe. Nicor Gas will submit a bill for any service pipe charges
in excess of the 60 ft. free allowance, such billing to be issued and paid separately
from the natural gas utility bill. |
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