Interconnection Application - Merrimac Light Department

CONTACT INFORMATION

Applicant Type *

Residential

Business

First Name *

Middle Initial

Last Name *

Street Address *

Apt/Suite

City *

State *

Zip *

Is the Mailing Address the same as above? *

Yes

No

Mailing Address *

Apt/Suite

City *

State *

Zip *

Phone

Cell Phone

Fax

Email *

ALTERNATIVE CONTACT INFORMATION

(e.g., system installation contractor or coordinating company)

First Name *

Last Name *

Mailing Address *

Apt/Suite

City *

State *

Zip *

Home Phone

Cell Phone *

Fax

Email

Ownership

(include % ownership by any electric utility)

FACILITY INFORMATION

Merrimac Municipal Light Department

Account Number *

Inverter Manufacturer

Model Name and Number

Quantity Used

Nameplate Rating

kW

kVA

AC Volts

Phase

Single

Three

System Design Capacity

kW

kVA

ELECTRICAL CONTRACTOR

First Name *

Last Name *

Phone *

Address *

Apt/Suite

City *

State *

Zip *

IEEE 1547.1 (UL1741) Listed?

Yes

No

Estimated Installation Date

Estimated In-Service Date

CUSTOMER SIGNATURE

I hereby certify that, to the best of my knowledge, all of the information provided in this application is true and I agree to the Terms and Conditions. *

I agree

Signature

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