Nicor Gas SINGLE METER SERVICE REQUEST 1145 9-07 (red fields are required)
Lot:
Block:
Subdivision Name: (or N/A)
Service Address:
Town:
State:
Zip Code:
Customer Name:
Current Mailing Address:
Mailing Town:
State:
Zip Code:
Builder Name:
Residence Area Code and Telephone Number:
Business Area Code and Telephone Number:
Ext.
Builder Headquarters Address:
Town:
State:
Zip:
Builder Email:
Jobsite Area Code and Telephone:
Service Township:
Service County:
Builder Fax Area Code and Number:
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)? Yes No


Proposed Appliances:
Range Water Heater Gas Heat Gas Dryer

Heated area is more than 3000 sq. ft. No    Yes
If yes, Total SqFtg.   Total BTUs
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

Remarks:


Date Service is Required:

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

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.