Service Completion Notification Form

This form is to be completed and submitted to the Permit Issuer and the Gas Supplier before the gas service will be unlocked.

"*" indicates required fields

Permit No*

Permit Issurer*

Installation Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Lot*

Plan*

Blk*

Qtr*

Sec*

Twp*

Rge*

Mer*

Contractor / Installer Name*

Contractor / Installer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contractor / Installer Phone*

Please enter number of appliances and total input BTU rating for each of the following

House Furnace(s)

Water heater

Fireplace

BBQ

Range

Dryer

Garage

Other

Air Test Duration*

Air Test PSI*

Gas Service Is Connected to Meter*

Yes

Your Name*

First Last

Gas Fitter Certificate No.*

Date*