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Application for Service Automated Document, Preliminary Statement Part A

Page 1 of 4


Form 62-0683


Advise letter 2863-G/3111-E
Revised
2007

Application for Service


Residential Single Family Dwelling




Please complete this application and submit the completed form to PG&E Application for Service at P.O. Box 28949 Fresno CA, 93729-8949. You
may also submit applications at http://www.pge.com/customer_service/new_construction_services or call 1-877-PGE-SRVC. *Indicates optional
fields.

Project Information Gas Service Electric Overhead Service Electric Underground Service
Date Initial Service Needed _____________________


Project Address or Lot Number ________________________________ City _______________________ County _____________ Zip _______
___
Single Family Dwelling ____________ Multiple Lots ___________ *Assessors Parcel ___________*Building Permit ___________________
___
Nearest Cross Street _______________________________________________________________________________________________________
Applicant / Company Name _________________________________________________________________________________________________

Day Phone __________________ *Cell Phone __________________ *Fax __________________ *Email address __________________________
(Correspondence will be sent via e-mail )
Applicant Address _____________________________________________ City ____________________________ State _______ Zip __________
Contract Information
Legal name to appear on contract _____________________________________________________________________________________________

*State of incorporation or LLC _______________________________________________________________________________________________

Name of person authorized to sign contracts __________________________________________
______ *Title_______________________________

First Name, Middle Initial, Last Name

Mailing address for contract ______________________________________________ City _____________________ State ______ Zip __________
Representative Information
(Party who will relay project information and updates to the PG&E representative)

Name of Representative ____________________________________________________________________________________________________
Day Phone __________________ *Cell Phone __________________ *Fax __________________ *Email address ____________________
______
Mailing Address __________________________________ City ___________________________
State ________ Zip ___________
___
*Contractors Name ________________________________________________ *Contractors Phone ___________________________________
___

Credit Information (
Party responsible for energy use after the meter is installed)

Name/Company Name to appear on bill ___________________________
__ Day Phone ________________ *Evening Phone __________________

First Name, Middle Initial, Last Name
Mailing address for bill _______________________________________________ City _______________________ State _______ Zip _________

Individual Partnership Corporation
Limited Liability Corporation Governmental Agency Sole Proprietor Other__________
_

Individual Partnership Corporation
Limited Liability Corporation Governmental Agency Sole Proprietor Other__________
_
Individual Partnership Corporation
Limited Liability Corporation Governmental Agency Sole Proprietor Other__________
_ *Does the customer currently have service with PG&E? No Yes

*If yes, please provide the PG&E Account Number ___________________________________________________________________________
___

*Do you want the new service included on your existing bill? No Yes

*Desired Electric Rate Schedule ____________________________ *Desired Gas Rate Schedule _________________________________________
If you want additional information on rate options or want to request a free rate analysis, visit
http://www.pge.com/rates_regulations/rate_info/rate_options

or call 1-877-PGE-SRVC. If a rate schedule is not selected, PG&E will select an
applicable rate schedule.
Sept Applicant Design and Installation Options
As an applicant for new gas or electric service, you can choose either PG&E or a qualified contractor to design new gas/electric distribution and/or
service facilities. You can also choose either PG&E or a qualified contractor to construct all or a portion of new gas/electric distribution and/or
service facilities. PG&E will provide you with a bid for the design and the construction work
,
to assist you in making a selection. You will then have
the opportunity to choose either a qualified contractor to perform the design/or construction work.
In accordance with PG&Es filed tariffs, electric trenching, conduits, substructures and gas service trenching are the applicants responsibility. Once
you make a decision about who will perform the work, if you subsequently change your selection, you will be responsible for any re-engineering
charges incurred as a result of that change.
You should become familiar with the applicant design installation requirements, including PG&Es Applicant Design Guide and General Terms and
Conditions, before you make your selection. For copies of these documents and/or for addition information, visit
www.pge.com/applicantsdesignandinstall
or request information by call 1-877-PGE-SRVC.
Construction Information
Joint trench drawing to be prepared by:
Applicant
PG&E
Not required
Who will trench and backfill for the distribution facilities?
Applicant / Elec




PG&E / Elec


Date Joint Trench Required _____
Proposed distribution trench occupants or joint pole occupants: (check all that apply) Electric Gas Phone CATV Other ________
Who will install distribution conduit and substructures?

Applicant
PG&E
Who will trench and backfill for the service facilities?

Applicant / Gas
Applicant / Elec


PG&E / Gas
PG&E / Elec

Date Joint Trench Required _____


Proposed service trench occupants or joint pole occupants: (check all that apply)
Electric Gas Phone CATV Other _______

Who will install service conduit and substructures?
Applicant PG&E
*Transformer type requested:
Padmounted

Subsurface
(additional Special Facilities charges may apply)

Water, sanitary sewer, storm drain, low pressure gas, oil or other fluid carrying piping or facilities or private utilities (e.g. fire alarm, private
streetlight systems, private phone, private CATV or gate controllers) are not permitted in a PG&E occupied joint trench.
IMPORTANT NOTE: Do NOT install your electric main switch or gas house line until the location is approved by PG&E.
General Construction Information


Will temporary electric service be required?
No
Yes
Date needed _________________________________________________________


Will temporary gas service be required?

No
Yes Date needed___________________________________________________________
If, yes please complete the following:
Will Temporary Service power be operated for less than one year?
No
Yes
Have you ever completed a temporary power project with us before?
No
Yes

*Who will trench and backfill for Temporary Service?
Applicant/Gas
PG&E/Gas
Applicant/Electric
PG&E/Electric
Automated Document, Preliminary Statement Part A
Page
2 of 4


Form 62-0683


Advise letter 2863-G/3111-E
Revised Sept 2007

Electric Temporary Services
Panel, Main Breaker Size________ amps
*Will Applicant or Contractor Install Pole ?
No
Yes

Gas Temporary Services
*Gas Service Delivery Pressure Requested:
¼

other _____________

*Number of Meters at each service location? ______
*Total Ga