Please print name in the following statements in the space provided. Doing so will indicate that you have read and agreed to
the terms and conditions.
_, understand and agree to the conditions that the building or area for which temporary utilities is
approved is not to be occupied until the appropriate Certificate of Occupancy is issued. Failure to comply will result in the
disconnection of those utilities and may result in the revocation of permits.
_, understand that occupancy of new building/structures includes owner’s furnishings such as
desk, furniture, computers, stock, etc. If applicable I have informed the owner as well that failure to comply will result in the
disconnection of those utilities, may result in the revocation of permits and will required the removal of furnishings until
approved for either a TCO or CO as required by law.
_, understand and agree to the conditions that I as the applicant am responsible to maintain
energized electrical systems or that portion of the building containing the energized electrical system in a secure and locked
manner or under constant supervision to exclude unauthorized personnel.
_, understand and agree to the conditions that I as the applicant am responsible for ALERTING
ALL PERSONNEL WORKING in the vicinity of the energized electrical system to its presence. I fully understand that this
means all subcontractors and anyone who might be working in an area that could be harmed by energized systems or
_, if not the owner I state that I have informed the owner of the address indicated and that the
owner is also in agreement with all the terms of this temporary utility application. Owner verification:
I am the owner
I am not the owner but have discussed this application with the owner
_, hereby agree to indemnify, defend, and save harmless Brunswick County, its employees, and
the utility companies from any and all liability arising from utility services being either connected or disconnected from the
above-mentioned premises as requested/allowed by this application.
I acknowledge and agree that I have communicated, secured, and notified all parties as required in the above and
agree to all terms as set forth in this application:
Applicant Printed Name: __ _
Applicant Signature: _