Line Installation Permission Agreement

Line Installation Permission Agreement
IF YOU DO NOT OWN THIS PROPERTY, GIVE THIS FORM TO OWNER!

NO COST to bring this service to your location!

Casey Mutual Telephone Co. is requesting your permission to bury a line across your property as part of its construction project to bring Fiber to the Home to your neighborhood.
I would NOT want a drop brought up to my house
Signature if you do NOT want a drop

Clear
There will be a cost if you decide to have the line added at a later time!
Property Owner
Property Owner Contact Number
Address
City
Mailing Address(if different from above)
Tenant Name
Tenant Contact Number
Please enter a valid phone number.
Current Buried Underground Services

Power Lines-(RED)Tile Lines-(LIGHT BLUE)Well / Water Lines-(DARK BLUE)LP Tanks / Lines-(YELLOW)Septic System / Laterals-(GREEN)Communication Lines-(ORANGE)Invisible Fence-(PURPLE)GEO Thermal-(LIGHT GREEN)
Please use the coresponding color above to draw the location of the undergound services on the image (or the picture you upload) down below.

Technician please use pink for the ONT location
Please draw on the image (or add your own picture) below.
Please draw on the image (or add your own picture) below.
Please draw on the image (or add your own picture) below.
Please draw on the image (or add your own picture) below.
Describe location of buried underground services
Location of ONT
(field tech use only)
If property owner changes their mind about placement of services on their property after the execution of this document, it is the sole responsibility of property owner to notify CMTC of the withdrawal of their permission prior to construction beginning!
I ,_______ Property Owner at the above stated address, grant Casey Mutual Telephone the permission and an easement to bury a line across my property.
Print Name
Signature

Clear
Date

MonthDayYear
Date
Field Tech Name
Date Field Tech was at location.

MonthDayYear
Date
Should be Empty: