Name

    Mailing Address

    Physical Address of Work to Be Performed

    Phone Number
    E-mail Address
    Time Frame for Completion of Job

    Detailed Scope of Work including all appliance loads

    Type of equipment to be installed/altered/repaired

    Other

    Equipment related to electrical installation
    Brand Name

    KW rating

    Minimum Circuit Amps (MCA)
    Maximum Circuit Over Current Device (MCOPD)
    - max circuit breaker or fuse

    Amperage

    Wiring route
    Build construction type
    Finish

    Other
    Note potential hazards
    Place to turn around

    Do we have full access?

    Items to attach when applicable