Alternate Phone. Email Address: Owner Date of Birth: Owner Driver’s Lic.#/State: Tax ID#: Contractor Name: Contractor Address: This agreement is subject to the Terms and Conditions on the back of this agreement. The Narragansett Electric Company d/b/a National Grid (National Grid) agrees to install a gas service to the above location (Premises). I understand that I may cancel this agreement, without obligation, at anytime prior to the installation of the gas service line. I hereby authorize National Grid to install a natural gas service line to the address noted above. PAYMENT INFORMATION: Please do not send payment along with this contract. An invoice will be generated upon receipt of this application with the option to pay by check. Please note: all invoices must be paid within thirty days. Owner/Applicant Signature: Date: Contractor Signature: Date: Residence Type Gas Equipment (Please indicate below if Single family equipment is Existing = E or New = N) Multi family # Units Individual meters Heating ( Std HE ) Generator Heat Water Htg. Grill Non-heat Cooking Light House meter Drying Pool Htr. Single meters Fireplace Garage Htr. Planned Equipment installation date / / Site Information Surrounding Area: Wetlands/water Historic Nature Preserve Undeveloped Urban Corner Lot Public Road Private Roadway State Road (Please mark for meter location and indicate street and cross street names) 1 9 Cross Street Cross Street 2 8 3 7 4 5 6 Street Name House square footage: Mtr. location #: Distance of house to street: Distance from front ( right left ) corner of house: Mtr. location: Outside Marked Connection from (Street Name): Parking restrictions: Conditions on private property along proposed service route (check all that apply): Wall Flower Beds Walkway Driveway Sprinkler Cesspool/Septic Trees Ledge/Rock Underground electric/phone/cable Underground Oil Tank Waterline None of the above Target Date: All shaded areas are Target/Comp ID: for company use Work Order #: Easement Permits: Town State Conservation Private Road Describe work requested: Unit BTU/HR Heating BTU Rate Mtr. Size Mtr. 1 Mtr. 2 Mtr. 3 Mtr. 4 Mtr. 5 TOTAL Reviewed by: Date: Terms and Conditions of Residential Gas Service Agreement
Alternate Phone. Fax Number: Approximate Arrival Time: Return Time at End of Business Day: CHECK ALL THAT APPLY Food Supply Products Utensil W ashing Area Hot and Cold Water Available Frozen Food Storage Waste Water Disposal Method Mop Sink Wash Pads Food Preparation Space Vehicle and/or Cart Washing Sufficient Designated Storage Space Cold Storage Dry/Bulk Storage Overnight Storage Equipped wIth Electrical Power NOTE: COVERED AREA REQUIRED FOR CARTS Cart Vehicle Protected Water Source for Each Mobile Unit Sanitary Disposal of Grease Garbage Provide Other Service(s) Not Listed Indemnification: The Contractor agrees to indemnify, defend (with counsel reasonably approved by County) and hold harmless the County and its authorized officers, employees, agents and volunteers from any and all claims, actions, losses, damages, and/or liability arising out of this contract from any cause whatsoever, including the acts, errors or omissions of any person and for any costs or expenses incurred by the County on account of any claim except where such indemnification is prohibited by law. This indemnification provision shall apply regardless of the existence or degree of fault of indemnitees. The Contractor’s indemnification obligation applies to the County’s “active” as well as “passive” negligence but does not apply to the County’s “sole negligence” or “willful misconduct” within the meaning of Civil Code Section 2782. I, owner/manager of stated Commissary/Commercial Kitchen above, authorize MFF Owner, as stated above, of vehicle business stated above to use my facility for the above mentioned services, pursuant to California Retail Food Code (Cal Code), Chapter 10. I will notify San Bernardino County Environmental Health Services in writing upon termination of this agreement and/or when the operator no longer uses this facility, in compliance with Public Health regulations. NOTE: A NEW AGREEMENT IS REQUIRED AT THE TIME OF ANNUAL PERMIT RENEWAL. Electronic Signature Only: By checking this box, I confirm I am submitting this application electronically and that the information on this form is true and correct. I also acknowledge that I have read, understand and accept any terms and conditions of this form. Date: Commissary/Commercial Kitchen Owner/Manager Signature: Date: Print Name: Title: If more than one facility provides services in compliance with Sections 114294 – 114297 of Cal Code, copy this page and include a separate form for each facility. OUT OF COUNTY HEALTH DEPARTMENT FOOD ...
Alternate Phone. Email Address: Owner Date of Birth: Owner Driver’s Lic.#/State: Tax ID#: Contractor/Lic. Plumber Name: Contractor/Lic. Plumber Address: This agreement is subject to the Terms and Conditions on the back of this agreement. Brooklyn Union Gas Company d/b/a National Grid, NY (National Grid) agrees to install gas service to the above location (Premises). I understand that I may cancel this agreement, without obligation, at any time prior to the installation of the gas service line and main. I hereby authorize National Grid to install a natural gas service line to the address noted above. Unit BTU/HR Heating BTU Rate Mtr. Size Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 TOTAL Owner/Applicant Signature: Contractor Signature: Date: Date:
Examples of Alternate Phone in a sentence
City South Hadley State MAZip 01075 Primary Phone Alternate Phone Field not completed.
The COD System does not store a value for Alternate Phone 1 or Alternate Phone 2.
No. TRS Membership/Retirement NumberCity State Zip Code Primary Phone Number (Check one:( )Email Address Alternate Phone Number (Check one:( )Home HomeWork WorkMobile) Mobile) Check here if you entered new contact information above.
Business Phone Number Enter Business Phone number Alternate Phone Number Enter Alternate Phone Number Business Email Address Enter Business Email Address Fax Number Enter Fax Number BCEID User Name Enter BCEID User Name ☐ The contact is a legal entity, not a person, that has an interest (such as Shareholder) in the Institution.
First Name Last Name Relationship Primary Phone ( ) Alternate Phone ( ) First Name Last Name Relationship Primary Phone ( ) Alternate Phone ( ) Registration continues on next page.
More Definitions of Alternate Phone
Alternate Phone. Email: Community you wish to lead: By signing this Community Leader Agreement, you are agreeing to the reasonable expectations set out above, overleaf and within this manual. To comply with GDPR Data Protection laws you consent to us passing your contact details and other data to people who contact SAS to find out who the main community lead is in the area. You consent to us sharing the contact email address provided on our Plastic Free Communities map (xxxxx://xxx.xxx.xxx.xx/communities-near-me/) as a point of contact on your community pin. You also agree to us processing your data for the purposes of Plastic Free Coastlines, Plastic Free Communities, communication with you about your plastic free community and keeping you up to date about other SAS campaigns. Signature of Applicant……………………………………………………………………………………………………………………. Print Name…………………………………………………………………………………………………………………………. We are all connected through the Plastic Free Communities project due to our mutual desire to protect our environment and reduce our reliance on avoidable single-use plastics. If you haven’t already, sign up for an Individual Action Plan at xxxxxxxxxxx.xxx.xx as this is a good starting point to get underway with the project. Once again, thank you for support and welcome to the team! Let’s free where we live from single-use. Team SAS
Alternate Phone. Email: Day Phone: Alternate Phone: Email: Check Number: Cash Amount: Date Received: Name of Staff: CERTIFICATIOII BY APPLICAIIT: .. ) I do heteby .1ff11n\'With ,ny signattaethat I have,-e.ul this••1>1>lication. andth.1tall info,nl.l'tion cont.lined heteh, ist,ue andconeet ..tnd th.1t ..,11 1,eanesenta'lionsn1.:'ldebyn1e1eg;xxxxx n,y rec:1ue-stfo1 thist>etnlit .·neneithet fJ.lseno, n""1isretnesented. I undetstandthat any f.1lsehoodor n1isre,,resentation rnadein this.11>1>tic.1tion n ....,ybea crinlinal violJttion of theCodeof theCityof Maiitlo.'lnd. I do hetby cettifyth.1t I have1eceived
Alternate Phone. Email Address: Owner Date of Birth: Owner Driver’s Lic.#/State: Tax ID#: Contractor Name: Contractor Address: This agreement is subject to the Terms and Conditions on the back of this agreement. The Narragansett Electric Company d/b/a National Grid (National Grid) agrees to install a gas service to the above location (Premises). I understand that I may cancel this agreement, without obligation, at anytime prior to the installation of the gas service line. I hereby authorize National Grid to install a natural gas service line to the address noted above. PAYMENT INFORMATION: Please do not send payment along with this contract. An invoice will be generated upon receipt of this application with the option to pay by check. Please note: all invoices must be paid within thirty days. Owner/Applicant Signature: Date: Unit BTU/HR Heating BTU Rate Mtr. Size Mtr. 1 Mtr. 2 Mtr. 3 Mtr. 4 Mtr. 5 TOTAL
Alternate Phone. Email Address: Owner Date of Birth: Owner Driver’s Lic. #/State: Tax ID#: Contractor Name: Contractor Address: This agreement is subject to the Terms and Conditions on the back of this agreement. The Narragansett Electric Company d/b/a National Grid (National Grid) agrees to install a gas service to the above location (Premises). I understand that I may cancel this agreement, without obligation, at anytime prior to the installation of the gas service line. I hereby authorize National Grid to install a natural gas service line to the address noted above. Unit BTU/HR ADTH Rate Mtr. Size Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 TOTAL
Alternate Phone. Email Address: Owner Date of Birth: Owner Driver’s Lic. #/State: Tax ID#: Contractor Name: Contractor Address: This agreement is subject to the Terms and Conditions on the back of this agreement. KeySpan Gas East Corporation, d/b/a National Grid, NY (National Grid) agrees to install gas service to the above location (Premises). I understand that I may cancel this agreement, without obligation, at any time prior to the installation of the gas service line and main. I hereby authorize National Grid to install a natural gas service line to the address noted above. Unit BTU/HR Heating BTU Rate Mtr. Size Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 Xxx. 0 TOTAL
Alternate Phone. Email: Age: DOB: Gender: Marital Status: Referred by: Organization: Guarantor (if other than the patient): Relation to the patient: Address: Same as above City: State: Zip: Phone: Same as above Email: Same as above Please note: Session fees vary by therapist. For individual, couples, and family therapy sessions, fees range from $160 to $275 for a 60 minute session Group Therapy Session, 60 minutes $110 ADHD Screening $350 to $450 Court Documents, Expert Witness Testimony and Reunification Work, 60 minutes $360 Policies
Alternate Phone. Email: IT IS MUTUALLY AGREED: