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a i <br /> r('�.,DUKE <br /> �' ENERGY. <br /> SELF INSPECTING AGENCY RELEASE FORM <br /> Duke Energy is dedicated to providing safe connection of electric servic�to our <br /> customers. <br /> In order to expedite the connection of electric service and ensure the electrical integrity of <br /> all"self-inspected" (ocations, we ask that the following information be completed and <br /> faxed to Duke Energy's Commercial, Governmental, and Industrial Department at 1-877- <br /> 276-3773. � <br /> Address: �75�( _�eJKe,►� f}.v� ��Ll�� ��� <br /> City: ZG Pl.yr�rl f_� <br /> County: Pa�s'�n - - _ - <br /> Self-Inspecting Agency: �['�''�/ m�_ ��G,��-���� � <br /> Completion of this Release and Authorization certifies that the property listed above has <br /> been inspected and that it meets the requirements necessary to permit the electrical <br /> system to be attached to the electrical system of Duke Energy and to receive electric <br /> energy service. By executing and forwarding this Release and Authorization the"self- <br /> inspecting"agency assumes any and all liability for the failure of the electrical system to <br /> be properly installed to receive electric energy and the seIf-inspection agency hereby <br /> indemnifies and agrees to hold Duke Energy harmless from any and all claims that arise <br /> as a result of the electric system and failure, including any failure of the circuit <br /> connecting this property to Duke Energy's existing electric system. <br /> Completion of this release and authorization further certifies that the properiy to receive <br /> service qualifies for self-inspection and has been inspected to the satisfaction of the <br /> inspecting agency and that Duke Energy is authorized to connect electric service. <br />' Receipt of this release and authorization is a condition precedent to Duke Energy <br /> delivering service at this location and the indemnification rovided for in this <br /> P <br /> certification is speci argained for between the parties. <br /> Authorizedby: _� PrintName: (��,v-lfhc-� � . ����-c"�,SS <br /> Title: �U)`l�1 �� ��� Phone Number: �� 7�, d r O c�Z� <br /> (Example: School Board Official) <br />, ' CommePc➢al Iedustriel and Govern <br /> � , mental Department: <br /> 5225 Tech Data Dr, Clearwater FI 33761 <br />� Phone: 877-342-5372 Fax: 877 276-3773 , <br />� A Duke ne <br /> E rgy Company <br />