Double Pole Survey Sheet

• Conducted on

  Date

• Prepared by

• Employee Number

• Ticket #

• Supervisor's Approval

  Sign

Tel Co: (If Different)

• Tel Co

• Route #

• Pole #

Elec. Co

• Elec Co

• Route #

• Pole #

Pole

• Pole 1

  Eversource

  Verizon

• Pole 2

  Eversource

  Verizon

Pole Location and Double Pole Information

• State

• Municipality

• Street Name

• Cross Street

• Comments

• Reason Code

  Relocation

  Replacement

• Pole Set Date

  Date

• Remedation Party

  Eversource

  Verizon

• Remedation Condition

  Butt In

  Chunked

  Pole Top Remaining

• Police Detail Required for Pole Removal?

  Yes

  No

  N/A

• Resurfacing Requirements

  Select Concrete None Asphalt Grass Dirt Other

  • Concrete
  • None
  • Asphalt
  • Grass
  • Dirt
  • Other

• Specify

• Type of Riser on Pole

  Primary Electric

  Secondary Electric

  Telephone Riser

  CATV

Attache Information: Please status all attachments either ON or OFF the OLD Pole

• Tap "+" to list order details

• Attachment Types

  Select Primary Electric Secondary Electric Fiber (IE: Eversource.com) Street Light Fire Alarm Private CATV CATV Telephone Others

  • Primary Electric
  • Secondary Electric
  • Fiber (IE: Eversource.com)
  • Street Light
  • Fire Alarm
  • Private
  • CATV
  • CATV
  • Telephone
  • Others

• Specify

• Attachment is transferred off old pole

• Attachment is still on old pole

• Attache Company Name (Please identify attachment to assist with party transfer notifications)

Additional Equipment attached to pole **Please note**

• Select

  Transfer

  Capacitor

  Switches

  Arestors

  Other

• Specify