Construction Request - Residential

Contact Information

Home Owner:

Last Name *This question is required.

First Name *This question is required.

Middle Name

Employer *This question is required.

Daytime Phone *This question is required.

Cell Phone

Email *This question is required. This question requires a valid email address.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Mailing Address

Address *This question is required.

Apartment/Unit Number

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Builder/Contractor Information

Builder/Contractor:

Company Name *This question is required.

Name of Contact *This question is required.

Company Phone *This question is required.

Contact Phone

Fax

Email *This question is required. This question requires a valid email address.

Mailing Address

Address *This question is required.

Apartment/Unit Number

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Billing Information

Existing Superior Water, Light & Power Customer? *This question is required.

Existing Account Number *This question is required. This question requires a valid number format.

Name (if different than above)

Last Name

First Name

Middle Name

Primary Phone

Email This question requires a valid email address.

Additional Name on Account (if applicable)

Last Name

First Name

Middle Name

Primary Phone

Email This question requires a valid email address.

Billing Address

Address

Apartment/Unit Number

City

Zip Code This question requires a valid number format.

Project Location

Address *This question is required.

Apartment/Unit Number

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Legal Description

Lot Number

Block Number

City/Twp Name

Parcel

Project Instructions

Building Type *This question is required.

Please enter an 'other' value for this selection.

Current Construction Status *This question is required.

Customer Construction Start Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Approximate Install Dates

Electric This question requires a valid date format of MM/DD/YYYY.

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Gas This question requires a valid date format of MM/DD/YYYY.

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Water This question requires a valid date format of MM/DD/YYYY.

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Are any members of your household on life support equipment that relies on electrical service? *This question is required.

Contractor Information

	General Contractor	Electrical Contractor	Heating/Plumbing	Other
	General Contractor	Electrical Contractor	Heating/Plumbing	Other	Company	General Contractor	Electrical Contractor	Heating/Plumbing	Other
Contact Person	General Contractor	Electrical Contractor	Heating/Plumbing	Other
Phone Number	General Contractor	Electrical Contractor	Heating/Plumbing	Other
Fax Number	General Contractor	Electrical Contractor	Heating/Plumbing	Other
Email	General Contractor	Electrical Contractor	Heating/Plumbing	Other