Free Peco Service And Meter Application PDF Form Get Document

Free Peco Service And Meter Application PDF Form

The Peco Service and Meter Application form is a document required for individuals and businesses seeking electric service from PECO Energy. This form collects essential information about the applicant, service location, and specific service requirements to ensure a smooth application process. Completing this form accurately is crucial to avoid delays in service initiation.

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Outline

The Peco Service and Meter Application form is a crucial document for anyone seeking electric service from PECO. This form guides users through the process of applying for new service, upgrading existing service, or even requesting temporary service. It requires essential information such as the customer's name, service location, and the type of request being made. Additionally, applicants must provide their driver's license number or Social Security number, as well as their PECO account number if applicable. The form also includes sections for electricians or contractors to fill out, ensuring that they provide details about the construction status and the specific service characteristics needed. Load characteristics and motor information are also requested, which helps PECO determine the appropriate service requirements. Lastly, it is vital to remember that the application must be signed and dated to be processed. Incomplete submissions may lead to delays, so thoroughness is key when filling out this form.

Key takeaways

Filling out the PECO Service and Meter Application form correctly is crucial for a smooth process. Here are key takeaways to keep in mind:

  • Identify the Appropriate Office: Begin by locating the PECO regional office relevant to your service request. Ensure you check the correct box on the application.
  • Provide Accurate Customer Information: Fill in your name and service location. Include your Driver's License Number or Social Security Number as required.
  • Billing Address: Clearly state your PECO billing address or account number from the last 60 days to avoid confusion.
  • Electrician or Contractor Details: If applicable, include information about your electrician or contractor, including their Tax Identification number and preferred reply date.
  • Construction Status: Indicate your current construction status and specify the date you are requesting PECO service. Avoid vague terms like "as soon as possible."
  • Load Characteristics: Complete the load characteristics table, providing details on connected KW, maximum summer KW demand, and maximum winter KW demand.
  • Motor Information: If relevant, include details about motor specifications to ensure proper service setup.
  • Additional Comments: Use the comments section to provide any extra information that may assist in processing your application.
  • Sign and Date: Do not forget to sign and date the application. An unsigned form may lead to delays.

Completing the application thoroughly and accurately will help expedite the service request process. Ensure all information is clear to avoid unnecessary delays.

Form Preview Example

INSTRUCTIONS FOR PREPARING APPLICATIONS FOR ELECTRIC SERVICE & METER

Please refer to the sample application while reviewing the following notes. The letters below correspond with those on the sample. NOTE: THE "BLANK" FORM IS BELOW THE "SAMPLE" FORM

A.After reading the instructions at the top of the application, locate the PECO regional office in which the service is requested. Check the appropriate box and mail or fax the completed application to the appropriate regional office.

B.Complete the fields for customer's name and service location. Customer's Driver's License Number or Social Security Number is now required.

Note: (*) Include PECO Energy pole # and/or Lot # only if applicable.

(**) Use the address of the service when applying for underwriter's inspection.

C.Complete the fields for customer's PECO billing address or account number (within last 60 days).

D.Complete fields regarding you as the electrician or contractor, and indicate where you would like the reply sent. The Electrician/Builder Tax Identification number is now required. Also, please include the date you would like the reply returned to you.

E.Indicate your current construction status, and include the date PECO service is requested. Please avoid using "as soon as possible".

F. thru J. Indicate the following:

Type of Request

Type of Service (include number of units and area per unit)

Service Characteristics

Meter Information

Heating/Air Conditioning

K.Complete the table concerning the load characteristics of the service. For each applicable type of load, provide: 1) Connected KW, 2) Maximum Summer KW Demand, and 3) Maximum Winter KW Demand.

L.Complete the table concerning motor information.

M.If compensated metering will be used, indicate totalizer and general load (KW).

N.Include any additional comments.

O.

Application MUST be signed and dated.

Forms Rev. 5/18

PECO

Application for Electric Service & Meter

M-24175 (front) Rev. 5/18

INSTRUCTIONS:

Please complete the front page of this request and return to the PECO Regional Office (listed below) in the area service is required. Incomplete information may result in a delay in processing.

All work must comply with PECO Electric Service Requirements manual and be inspected by an approved inspection agency. (City of Philadelphia requests may be shared with Licenses & Inspections). Not all service voltages are available in all areas. Before purchasing electrical equipment or proceeding with any wiring, information regarding service availability and meter location should be obtained from the company.

A credit application and agreement must be completed if the customer has not had PECO service within the last 60 days. The company reserves the right to cancel this request if no further communication is received from the customer within 90 days of PECO's response date.

NOTE: IF DEMOLISHING A BUILDING AND NEED PECO TO REMOVE ELECTRIC OR GAS FACILITIES, PLEASE CALL 8-1-1 (PA ONE CALL) FOR DEMOLITION REQUEST

NEW BUSINESS SERVICES (1-800-454-4100) http://www.peco.com

PHILADELPHIA

 

 

 

DELAWARE & CHESTER COUNTIES

BUCKS & MONTGOMERY

 

 

 

 

 

 

 

NEW RESIDENTIAL

 

 

 

 

 

 

COUNTY

 

 

 

1050 W. Swedesford Rd.

COUNTIES

 

 

 

 

 

 

 

 

 

CONSTRUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

830 S. Schuylkill Ave.

Berwyn, PA 19312

 

 

 

 

400 Park Ave.

 

 

 

 

 

 

 

 

 

(All Counties)

 

 

 

 

 

 

 

 

 

 

Philadelphia, PA 19146

Email:DelChesterServiceApplications@ex

Warminster, PA 18974

 

 

 

 

 

 

 

 

 

400 Park Ave.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email:PhilaNewBusiness@e

eloncorp.com

 

 

 

 

 

 

 

Email:Bucksmontserviceapplications@e

Warminster, PA

18974

 

 

 

 

 

 

 

 

 

xeloncorp.com

 

 

 

Fax # (610) 725-1416

 

 

 

 

xeloncorp.com

 

 

 

 

 

 

 

 

 

Email:NRCGMETERORDERS@P

Fax # (215) 731-2327

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax # (215) 956-3240

 

 

 

 

 

 

 

 

 

eco-Energy.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax # (215) 956-3380

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER NAME

 

 

 

 

 

 

 

 

 

 

 

 

Tax ID # or SSN

 

 

TYPE OF REQUEST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Service

 

 

Load Increase/Decrease

 

Reintroduction of Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Temporary Service

Upgrade/Changes

 

Demolition (Remove

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separation of Wiring

Service Relocation

 

 

 

Service)

 

 

 

 

 

 

** ADDRESS TO BE SERVED

 

 

B

 

 

 

 

 

APARTMENT/LOT #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

Make-Safe (De-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

energize/Cover)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

 

TYPE OF SERVICE: Please include site plan.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENTIAL

 

 

 

 

 

 

 

 

 

 

 

 

COMMERICAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single House

Mobile Home

Store

 

 

 

 

Office

 

 

 

G

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment

Modular Home

Industrial

 

 

 

 

Warehouse

 

 

 

UTILITY POLE#

SUBDIVISION/DEVELOPMENT

 

 

TOWNSHIP/MUNICIPALITY/WARD#

 

Duplex

Town House

Restaurant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other _____________________________

Other _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area of Building _______________________ Sq. Ft.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* If Applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICE CHARACTERISTICS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

** Please use this address when applying for underwriter’s inspection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHASE

 

VOLTS

 

 

 

WIRES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Underground

 

 

Aerial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMERS BILLING ADDRESS

 

C

 

 

-OR-

 

 

PECO ENERGY ACCOUNT#

 

 

 

 

 

 

 

 

 

 

3

 

 

240

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMPS _________

 

 

 

 

 

3

 

 

120/240

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHASE

 

VOLTS

 

WIRES

 

 

 

 

 

 

 

3

 

 

120/208

 

 

 

4

 

 

 

 

CITY, STATE

 

 

ZIP CODE

 

 

 

 

 

TELE. #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

120

 

 

2

 

 

 

 

 

 

 

 

3

 

 

277/480

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

120/240

 

3

 

 

 

 

 

 

 

 

3

 

 

13200

 

 

 

3 or 4

SEND REPLY TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

120/240

 

5

 

 

 

 

 

 

 

 

3

 

 

33000

 

 

 

3 or 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ELECTRICIAN’S OR BUILDER’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

METER INFO:

Two Meters, Commercial (General/Totalizer)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single Meter Required

 

 

 

 

 

 

 

Multiple Meter Total No. _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

Reply Requested by:

 

 

HEATING/AIR CONDITIONING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

 

 

 

 

 

 

/

/

 

 

 

Central Air _____ Tons

 

Resistance

 

 

 

J

 

Heat Pump _____ Tons

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Natural Gas

 

 

 

Propane

 

 

 

 

Type Back-Up _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

 

CHARACTERISTICS OF NEW OR ADDITIONAL LOAD:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONNECTED

 

PECO ENERGY USE ONLY (DEMAND)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE

 

LOAD (kW)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELE. #

 

 

 

 

 

 

 

 

 

 

E-MAIL ADDRESS

 

 

 

 

 

SUMMER (kW)

 

 

 

Winter (kW)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIGHTING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT CONSUTRCTION STATUS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEATING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not Started – Date Customer Will Start Work: _____/_____/_____

In Progress Completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AIR/COND.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approximate Date Service Requested: _____/_____/_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

TANKLESS WATER HTR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MISC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER COMMENTS/ DESCRIPTIN OF WORK

 

 

N

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Include single line diagram and substation arrangement if appropriate.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LARGEST MOTOR SPECIFICATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

QUANTITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALIZER LOAD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIZE (HP)

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCKED ROTOR CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR CODE LETTER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMITTED BY: _________________________________ DATE: ______________________

 

PHASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENERAL LOAD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOLTAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PECO

Application for Electric Service & Meter

M-24175 (front) Rev. 5/18

Enclosures: Site Plans Single Line Diagram Substation Arrangement

FREQ. OF STARTING (PER HR.)

PURPOSE

KW

INFORMATION BELOW WILL BE FILLED IN BY PECO:

 

 

 

 

 

 

 

 

 

 

 

Service Request No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUS/MAJ ACCT REP

 

TELEPHONE

DATA RECEIVED

DESIGNER

 

 

 

 

 

DATA RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POL SUB

 

RATE

 

RIDER

 

CONTRACT LIMITS

 

SIC NUMBER

 

T

 

DATE REPLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER

 

COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMPS

 

WIRES

 

VOLTAGE

PHASE

 

 

CIRCUIT

 

 

 

 

 

C-QUAD

 

T-QUAD

LOAD (KVA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUMMER_____WINTER ____

SERVICE CHARACTERISITICS – Select One from Each

 

 

 

 

 

 

 

 

 

POLE # / MH # LOCATION

 

CUT THROUGH DATE

SERVICE TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aerial

 

 

 

Underground

URD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential

 

 

Comm (Non-

 

Comm (Demand)

 

HT/PD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Demand)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENERATION PROCUREMENT CLASS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class 1 (Residential)

 

 

 

Class 2 (Commercial, less than 100kW)

 

 

 

 

 

 

 

 

 

 

 

 

Class 3 (Commercial, 100kW to 500kW)

 

Class 4 (Commercial, greater than 500kW)

 

 

 

 

 

 

 

 

 

 

NOTE: The customer’s Initial Procurement Class will be determined by PECO, based on peak load

 

 

 

 

 

 

estimates for the first year of service. The customer’s Procurement Class will be adjusted each year,

 

 

 

 

 

 

based on actual usage.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

METER TYPE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KWH

 

 

IND. DEMAND

RECORDER

TOU

 

 

 

 

 

 

 

 

 

 

SERVICE PHASING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SINGLE PHASE

TWO PHASE

THREE PHASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICE REQUIREMENTS:

 

 

 

 

 

 

METERING LOCATION AND REQUIREMENTS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Present Location:

Meter # _______________

CTs-

PTs-________

Present Service OK

Loop Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________

 

 

Taps Only

 

 

See Job # ________________________________

 

Indoo

Outdoor

 

On ________ Wall, ________ Ft. From ________ Wall, ________ ft. Above

 

 

 

 

 

 

 

 

 

 

r

 

 

 

 

 

Ground

 

 

 

ADVANCE NOTIFICATIONS:

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER BILLING:

 

 

 

Underwriter’s Cert.

 

Yes

No

 

 

 

 

 

 

 

 

 

Advance Billing

Yes

 

$_______________

Required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Required

 

 

 

__

Customer to Trench

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

No Customer

 

 

Permit Required

 

Yes

No

State

Other

 

 

 

 

 

 

 

Charges:

$_______________

 

 

 

 

 

 

 

 

 

 

 

__

 

 

 

 

 

 

 

 

_______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cust. #

 

 

Date

 

 

ACT 222 Cert. Required

 

Yes #

 

 

No

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________

 

___________________________

 

 

 

_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BTCO #

 

 

Date

 

 

PA One Call #

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________

 

___________________________

___________________________

 

 

 

 

__________________________

 

 

 

 

 

 

 

CATV #

 

 

Date

 

 

Gas

BTCO

CATV

Other

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________

 

___________________________

 

 

 

 

 

___________________

__________________________

 

 

 

 

 

 

 

 

Other

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________________________

 

___________________________

SKETCH / INSTRUCTIONS

PECO

Application for Electric Service & Meter

M-24175 (front) Rev. 5/18

INSTRUCTIONS:

Please complete the front page of this request and return to the PECO Regional Office (listed below) in the area service is required. Incomplete information may result in a delay in processing.

All work must comply with PECO Electric Service Requirements manual and be inspected by an approved inspection agency. (City of Philadelphia requests may be shared with Licenses & Inspections). Not all service voltages are available in all areas. Before purchasing electrical equipment or proceeding with any wiring, information regarding service availability and meter location should be obtained from the company.

A credit application and agreement must be completed if the customer has not had PECO service within the last 60 days. The company reserves the right to cancel this request if no further communication is received from the customer within 90 days of PECO's response date.

NOTE: IF DEMOLISHING A BUILDING AND NEED PECO TO REMOVE ELECTRIC OR GAS FACILITIES, PLEASE CALL 8-1-1 (PA ONE CALL) FOR DEMOLITION REQUEST

NEW BUSINESS SERVICES (1-800-454-4100) http://www.peco.com

PHILADELPHIA COUNTY

DELAWARE & CHESTER COUNTIES

BUCKS & MONTGOMERY

 

 

 

 

 

NEW RESIDENTIAL

 

 

 

830 S. Schuylkill Ave.

1050 W. Swedesford Rd.

 

COUNTIES

 

 

 

 

 

 

 

 

CONSTRUCTION

 

 

 

Philadelphia, PA 19146

Berwyn, PA 19312

 

400 Park Ave.

 

 

 

 

 

 

 

 

(All Counties)

 

 

 

 

 

 

Email:PhilaNewBusiness@ex

Email:DelChesterServiceApplications@exe

Warminster, PA 18974

 

 

 

 

 

 

400 Park Ave.

 

 

 

 

 

 

eloncorp.com

 

 

loncorp.com

 

 

 

Email:Bucksmontserviceapplications@e

 

Warminster, PA 18974

 

 

 

Fax # (215) 731-2327

Fax # (610) 725-1416

 

xeloncorp.com

 

 

 

 

 

 

 

 

Email:NRCGMETERORDERS@P

 

 

 

 

 

 

 

 

 

 

Fax # (215) 956-3240

 

 

 

 

 

 

eco-Energy.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax # (215) 956-3380

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER NAME

 

 

 

 

Tax ID # or SSN

 

 

 

TYPE OF REQUEST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Service

 

 

Load Increase/Decrease

 

Reintroduction of Service

 

 

 

 

 

 

 

 

 

 

 

 

Temporary Service

Upgrade/Changes

 

Demolition (Remove

** ADDRESS TO BE SERVED

 

 

APARTMENT/LOT #

 

 

 

Separation of Wiring

Service Relocation

 

 

Service)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make-Safe (De-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

energize/Cover)

 

 

 

CITY, STATE

 

 

 

 

ZIP CODE

 

 

 

TYPE OF SERVICE: Please include site plan.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENTIAL

 

 

 

 

 

 

 

 

 

COMMERICAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single House

Mobile Home

Store

 

 

 

 

Office

 

 

 

UTILITY POLE#

SUBDIVISION/DEVELOPMENT

 

TOWNSHIP/MUNICIPALITY/WARD#

 

Apartment

Modular Home

Industrial

 

 

 

 

Warehouse

 

 

 

 

 

 

 

 

 

 

 

 

Duplex

Town House

Restaurant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other _____________________________

Other _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area of Building _______________________ Sq. Ft.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*

If Applicable

 

 

 

 

 

 

 

 

 

SERVICE CHARACTERISTICS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**

Please use this address when applying for underwriter’s inspection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHASE

 

VOLTS

 

WIRES

 

 

 

 

 

 

 

 

 

 

 

 

 

Underground

 

 

Aerial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMERS BILLING ADDRESS

 

 

PECO ENERGY ACCOUNT#

 

 

 

 

 

 

 

 

 

 

3

 

 

240

 

3

 

 

 

 

 

 

 

-OR-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMPS _________

 

 

 

 

3

 

 

120/240

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHASE

 

VOLTS

 

WIRES

 

 

 

 

 

3

 

 

120/208

 

4

 

 

CITY, STATE

 

ZIP CODE

 

TELE. #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

120

 

 

2

 

 

 

 

 

3

 

 

277/480

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

120/240

 

3

 

 

 

 

 

3

 

 

13200

 

3 or 4

 

SEND REPLY TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

120/240

 

5

 

 

 

 

 

3

 

 

33000

 

3 or 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ELECTRICIAN’S OR BUILDER’S NAME

 

 

 

 

 

 

 

METER INFO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Two Meters, Commercial (General/Totalizer)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single Meter Required

 

 

 

 

 

Multiple Meter Total No. _____________

ADDRESS

 

 

 

 

Reply Requested by:

 

 

 

HEATING/AIR CONDITIONING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

Central Air _____ Tons

 

Resistance

 

 

 

 

 

Heat Pump _____ Tons

 

 

 

 

 

 

 

 

 

Natural Gas

 

 

 

Propane

 

 

 

 

 

Type Back-Up _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other ________________

CITY, STATE

 

 

 

 

ZIP CODE

 

 

 

CHARACTERISTICS OF NEW OR ADDITIONAL LOAD:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONNECTED

 

PECO ENERGY USE ONLY (DEMAND)

TELE. #

 

 

 

 

E-MAIL ADDRESS #

 

 

 

 

 

TYPE

 

LOAD (kW)

 

SUMMER (kW)

 

Winter (kW)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIGHTING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT CONSUTRCTION STATUS:

 

 

 

 

 

 

 

HEATING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not Started – Date Customer Will Start Work: _____/_____/_____  In Progress Completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AIR/COND.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approximate Date Service Requested: _____/_____/_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TANKLESS WATER HTR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MISC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER COMMENTS/ DESCIPTION OF WORK:

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Include single line diagram and substation arrangement if appropriate.

 

 

 

 

 

 

 

 

 

 

 

 

LARGEST MOTOR SPECIFICATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUANTITY

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALIZER LOAD

 

 

 

 

 

 

 

 

 

 

 

 

SIZE (HP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCKED ROTOR CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR CODE LETTER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMITTED BY: _________________________________ DATE: ______________________

 

 

PHASE

 

 

 

 

 

 

 

 

 

 

 

 

 

GENERAL LOAD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOLTAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PECO

Application for Electric Service & Meter

M-24175 (front) Rev. 5/18

Enclosures: Site Plans Single Line Diagram Substation Arrangement

FREQ. OF STARTING (PER HR.)

PURPOSE

KW

INFORMATION BELOW WILL BE FILLED IN BY PECO:

 

 

 

 

 

 

 

 

 

 

 

Service Request No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUS/MAJ ACCT REP

 

TELEPHONE

 

DATA RECEIVED

DESIGNER

 

 

 

 

 

 

DATA RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POL SUB

 

RATE

 

RIDER

 

CONTRACT LIMITS

 

SIC NUMBER

 

 

T NUMBER

 

DATE REPLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMPS

 

WIRES

 

VOLTAGE

PHASE

 

CIRCUIT

 

 

 

 

 

C-QUAD

 

T-QUAD

LOAD (KVA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUMMER_____WINTER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____

SERVICE CHARACTERISITICS – Select One from Each

 

 

 

 

 

 

 

 

 

POLE # / MH # LOCATION

 

 

CUT THROUGH DATE

SERVICE TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aerial

 

 

 

Underground

 

URD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential

 

 

Comm (Non-Demand)

Comm (Demand)

 

HT/PD

 

 

 

 

 

 

 

 

 

 

 

 

GENERATION PROCUREMENT CLASS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class 1 (Residential)

 

 

 

Class 2 (Commercial, less than 100kW)

 

 

 

 

 

 

 

 

 

 

 

 

Class 3 (Commercial, 100kW to 500kW)

 

Class 4 (Commercial, greater than 500kW)

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: The customer’s Initial Procurement Class will be determined by PECO, based on peak load estimates for

 

 

 

 

 

 

 

 

 

 

the first year of service. The customer’s Procurement Class will be adjusted each year, based on actual usage.

 

 

 

 

 

 

 

 

 

 

METER TYPE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KWH

 

 

IND. DEMAND

 

RECORDER

TOU

 

 

 

 

 

 

 

 

 

 

 

 

SERVICE PHASING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SINGLE PHASE

TWO PHASE

 

THREE PHASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICE REQUIREMENTS:

 

 

 

 

 

 

METERING LOCATION AND REQUIREMENTS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Present Location:

Meter # _______________

 

CTs- ________

PTs-________

Present Service OK

Loop Only

 

 

 

 

 

Indoor Outdoor

On ________

Wall, ________ Ft. From ________ Wall, ________ ft. Above Ground

Taps Only

 

 

See Job # _________________________________

 

ADVANCE NOTIFICATIONS:

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER BILLING:

 

 

 

 

 

 

 

Underwriter’s Cert. Required

 

Yes

No

 

 

 

 

 

 

 

Advance Billing Required Yes

 

 

$_________________

Customer to Trench

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

No Customer Charges: $_________________

Permit Required

 

 

 

Yes

No

State

Other _______________________

Cust. # _________________________

Date ___________________________

ACT 222 Cert. Required

 

Yes # _____________

No

N/A

 

 

 

 

BTCO # ________________________

Date ___________________________

PA One Call # ___________________________

 

 

Date __________________________

CATV # ________________________

Date ___________________________

Gas

BTCO

CATV

Other ___________________

Date __________________________

Other __________________________

Date ___________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SKETCH / INSTRUCTIONS