Fillable Cell or Message Phone Middle Initial Employer Name

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Cell or Message Phone Middle Initial Employer Name

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File type: PDF

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Electric New Construction
Application–Residential
Lake Havasu:
Ph: 928-505-7016 Fax: 928-505-7032
2749 Maricopa Ave, Lake Havasu City, AZ 86406
Nogales:
Ph: 520-761-7951 Fax: 520-761-7947
861 W Mariposa Rd, Nogales, AZ 85621
Toll Free: 877-UES-4YOU (837-4968)
First
Middle Initial
City
State Zip
Work Phone
Employer Name
E-Mail Address
Phone Relationship
Kingman:
Ph: 928-681-8922 Fax: 928-681-8920
2498 Airway Ave, Kingman, AZ 86409
Applicant Information
Full Name: Last
Business Name (If Applicable)
Mailing Address
Home Phone
Cell or Message Phone
Day Year
Work Phone
Financially Responsible Party
Nearest Relative
Date (estimate) when power needed: Month
Spouse Information (If no spouse, please write None)
Spouse Name
Employer Name
Service Location Information
Service Address Cross Street City Zip
Township Range Section___ City County
Legal Description: Tract____ Block___ Lot ___ Subdivision
Is this property zoned A-R Agricultural – Residential? Yes or No (Mark one)
If yes, will there be more than one residential dwelling on this property? Yes or No (Mark one)
Parcel No: (Example: 310-06-025)
Type of Residence: House Mobile Home RV/Other:
Livable Square Footage: AMPS: 100 200 Other:
If structure is a manufactured building, date it will be moved into:
Type(s) of Service:
Permanent Construction Dusk-to-Dawn Light
Overhead
Temporary Construction NonPermanent (RV) Underground
Service Upgrade Change in Service
Note:
The residential temporary construction fee will be determined by the Engineering Department. Other rules and fees may apply according to the Rules and
Regulations approved by the Arizona Corporation Commission. “Electric Service Installation Requirements” booklets available online at www.uesaz.com, by mail or
in local office.
Builder/Contractor/Manufactured Home Dealer Phone
Electrician Phone
Note:
UniSource requires the Applicant to complete this Application and submit a plot plan. The Applicant is responsible for notifying UniSource when service pole
and service entrance ar installed and ready for service (City, County and/or State Inspections may be required prior to connection). A security deposit is required
when
meter is set or, in lieu of a cash deposit, a letter of credit from a previous electric utility company may be submitted. Established good credit with UniSource
Energy
Services is also acceptable.
Signature Date
click to sign
signature
click to edit
UniSource Energy Services
Plot Plan
Indicate North:
Legal Description:
Township Range Section
Subdivision
Block Lot Parcel
Address
Please enter the following Information:
1.
Property boundary dimensions, dimensions of all existing and proposed structures, and distances between all buildings.
2.
Location of public utility easement(s).
3.
Location of septic tank(s) and leach field(s).
4.
Location of proposed service entrance.
Rear Lot Line
Front Lot Line
Front Street
Nearest
Cr
oss
Str
eet:
Nearest
Cr
oss
Str
eet:
Indicate North:
UniSource Energy Services
Plot Plan Example
Legal Description:
Township
10N
Range
10W
Section
10
Subdivision
Sunny Arizona Ranchos, Unit 10
Block
10
Lot
10
Parcel
111-22-333
Address
1010 Your Property Street
Please enter the following Information:
1.
Property boundary dimensions, dimensions of all existing and proposed structures, and distances between all buildings.
2.
Location of public utility easement(s).
3.
Location of septic tank(s) and leach field(s).
4.
Location of proposed service entrance.
Rear Lot Line
Front Lot Line
Your Property Street
Front Street
Entrance
Water
--- --- --- --- --- --- --- --- --- --- --- ---Public Utility Easement (PUE) of 10 feet--- --- --- --- --- --- --- --- --- --- --- ---
--- ---75 feet--- ---
-- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 176 feet--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --
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Cell or Message Phone Middle Initial Employer Name

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Completed 4 April 2022

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