PERMIT NO. DATE
OWNER’S NAME
PHONE NO.
OWNER’S ADDRESS
JOB ADDRESS ZONE
IF COMMERCIAL:
BUSINESS NAME
COST OF PROJECT: $
FLOOD ZONE
ELECTRICAL CONTRACTOR
ELECTRICAL LICENSE NUMBER:
PHONE NO.
POWER
COMPANY: MS
SINGING RIVER
NAME POWER APPLICATION IS IN:
NATURE OF WORK YOU WILL BE PERFORMING:
FEES
EXISTING SERVICE SIZE
NEW SERVICE
SERVICE UPGRADE
MOVING SERVICE?
TEMP POWER POLE
110 CIRCUITS
220 CIRCUITS
COMMERCIAL
RESIDENTIAL
TOTAL
$
REMARKS:
SIGNATURE
DATE