Information

  • Address

  • Date

  • Prepared by:

Customer / Job Details

  • Name

Health, Safety and Environmental Issues

  • Dogs on site?

Special Consents Required

  • Landlord consent required?

  • Right of way?

  • Multi dwelling unit?

  • Heritage site or Building?

External Work

  • What is the customer's preferred installation method?

  • Chorus approval required

  • Add photo and drawing of preferred method

  • What is the customer's backup installation method?

  • Chorus approval required

  • Add photo and drawing of backup method

  • Customer consent to build when not home?

  • Location of ETP?

  • ETP location photo

  • Other requirements? I.e Traffic Management Plan, Arborist

  • What is required?

  • Special instructions and notes

External Work Consents - Boundary to ETP

  • Hole excavation and trenching?

  • Removal of concrete/tiling/pavement?

  • Installation of pipe(s)?

  • Clean up: We will leave the property in a clean and tidy state on completion. This does not include reinstatement to the same condition.

Internal Work

  • Location of ONT?

  • ONT location Photo

  • Underfloor access?

  • Ceiling access?

  • Special instructions and notes

Internal Work Consents

  • Drilling small holes and installation of hardware ?

  • Cutting holes in walls?

  • Exposed surface wiring?

  • Others?

Additional Notes

  • Notes

  • Add labelled photos using the 'inote HD' app

Signed Consent

  • I confirm that:
    - I have seen, read and understood this information and the end user terms and accept those terms; and
    - I agree to Chorus undertaking the installation works and method chosen at or on the property; and
    - I agree Chorus may share information it has gathered or holds about me with phone and broadband providers for the purpose of connecting my property to Chorus' network via fibre
    - If I am not the owner of the property, I understand that (i) I need to obtain the consent of the owner for the installation works, and (ii) the installation works won't proceed until I notify Chorus I have obtained consent of the owner for the installation works; and
    - I understand that there may be an impact on the operation of burglar and medical alarms, particularly monitored alarms. [Note: check with your alarm provider or telecommunications service provider]

  • Optional - Permission to contact for marketing or research purposes?

  • End user signature:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.