Nicor Gas SINGLE METER SERVICE REQUEST-Residential Only 1145 10-16

Bold fields are required

LOT / BLOCK / SUBDIVISION / SERVICE ADDRESS / SERVICE TOWN / STATE / ZIP CODE
CONTACT NAME (if applicable) / CUSTOMER/ BUILDER EMAIL ADDRESS / SERVICE TOWNSHIP / SERVICE COUNTY
CUSTOMER/ BUILDER NAME / MAILING ADDRESS / MAILING TOWN / STATE / ZIP CODE
CUSTOMER/ BUILDER- AREA CODE AND TELEPHONE NUMBER / CELLPHONE- AREA CODE AND TELEPHONE NUMBER / FAX- AREA CODE AND TELEPHONE NUMBER / PREFERRED CONTACT TYPE
Phone Email

Proposed Meter Location. Meter location cannot be more than five (5) feet beyond the front.

Location must be marked on foundation with paint or stake “G” for gas.

As you face the house from the street: Front Right Left

Vehicular Traffic: Pipeline safety regulations and Nicor Gas’s tariff require that meters must be protected from vehicular traffic at the customer’s expense. If a meter is installed within three feet of potential vehicular traffic, the cost of this required meter set protection (bollards) is your responsibility, and you will be contacted by a Nicor Gas Representative to arrange a site visit to evaluate the property and review the required bollard installation and associated costs.

Is the proposed meter location within 3 feet of vehicular traffic (driveway, roadway, parking lot, alley, etc.)? No Yes

Proposed Appliances:

***Standard delivery pressure is ¼ lbs.-(6” wc)

Equipment# of UnitsConnected BTU’s (CFH)

Gas Heat

Range

Water Heater

Tankless

Water Heater

Dryer

Boiler

Generator

Pool Heater

Outdoor Cooking

Other

Will Your Gas Load Requirements Exceed 300,000 BTU’s? No Yes If yes, Total BTUs:

What is the total square footage of the home?

Septic field? No Yes If yes, send plan. Location: Front Back Right Left

Type of ConstructionStage of Construction - Existing

Single family Condo Townhome No foundation-If no foundation, enter foundation backfill date:

Duplex Mobile home Foundation Shell Under roof Drywall

*Please order service at foundation stage to ensure that we have proper planning time to get gas installed in your expected timeframe

Winter Construction Costs: Nicor Gas may encounter winter construction conditions(including but not limited to frost, freezing and thawing, snow conditions, and adverse temperatures)during the period from November 15 through March 15 that increase installation costs. To request installation during this period, you must agree to pay for Nicor Gas’ estimated full distributed cost of the incremental activities required for installation if such winter construction conditions are encountered, which is $497.10 plus any applicable taxes per residential service.

Do you request that Nicor Gas install service between November 15 and March 15, at a cost of $497.10plus any applicable taxes per service if winter construction conditions are encountered? Yes No (If you do not check “Yes”, your service installation will not be scheduled between November 15 and March 15)

Date Service is Required: *Payment Permit/ Unusual conditions could cause delayed installation.

Approximately how far is the building/house from the road?

What is the name of the nearest cross street?

Within City Limits? No Yes

What direction are you from that street? N S E W

Do you have a sleeve installed? Y N

Remarks

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 or 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 but 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 with the Illinois Commerce Commission including Rider4-Gas Service Pipe. Nicor Gas will submit a billfor any service pipe charges in excess of the 60 foot free allowance, and any applicable governmental permit fees required such billing to be issued and paid separately from the natural gas utility bill.

Applicant Date

Please sign and fax promptly to Nicor Gas, at 630-305-0466, or complete the form on the internet at

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