Name and Address of Equipment Purchaser
Name and Address of Property Owner
____________________________________________ __________________ ________________
Property Owner’s Name Home Telephone Work Telephone
____________________________________________ __________________ _____ ________
Mailing Address City State Zip Code
Name of Customer and Address of installed Equipment if different
____________________________________________ __________________ ________________
Customer Name Home Telephone Work Telephone
____________________________________________ __________________ ______ ________
Installation Address City State Zip Code
I hereby acknowledge and agree that I will be placed on a different rate as a result of the Property Owner’s actions, and agree to grant access to AMU for periodic inspections.
_____________________________________________ ________________________________
Customer Signature (if not Owner) Date Signed by Customer
(Owner also signs here if he or she is the customer at the address the equipment is installed)
Dealer Information
____________________________________ ______________________________ _______________
Dealer Name Contact Telephone
Equipment Information-Electric Heating System TYPE:_____________________________________
__________________ _____________________ __________ _______________ ______________
Make Model Fuel Source Size (BTU or kW) Install Date
Description of Residential or Small Commercial Structure
__________ __________ ____________ ______________ ___________ ___________
New/Existing Area (Sq Ft) Full/Partial Bsmt Heated Area (Sq Ft) R-Value Walls R-Value Attic
_____________________________ _________________ __________________________
Heat Gain/Loss (Dealer Calculation) % Electrically Heated Previous Heating System (if any)
Water Heater In Use (Please Mark All That Apply)
Electric ______ Check if New W/H ______ Size_________ Gallons
Gas / Propane ______ Check if High Efficiency W/H_____
_________________________________________ _________________________________________
Owner’s Signature/Date Signed Dealer’s Signature/Date Signed
Date Received ______________ Date Verified __________________ by ________________________
_____Accepted _____Refused Date:_________________
Date Rate Code Effective ________________ Customer Rate Code ____________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- me and name or name and i
- name and i vs name and me
- name and i or name and myself
- name and address worksheets printable
- name and i or name and me
- address of nyc office of labor relations
- telephone number and address book
- kinds of equipment list aviation
- printable name and address sheets
- inventory of equipment template
- address of bank of america hq
- merge last name and first name excel