UFB Connect Scoping Form - Electronet V.2

• Address

• Date

  Date

• Prepared by:

Customer / Job Details

• Name

• Contact

Next Actions

• What outside installation method is to be completed?

  Select 1. Aerial 2. Existing Duct 3. Surface Mount Cable 4. Shallow Trench 5. Drill or slot Trench in Concrete 6. Hard Surface Trenching

  • 1. Aerial
  • 2. Existing Duct
  • 3. Surface Mount Cable
  • 4. Shallow Trench
  • 5. Drill or slot Trench in Concrete
  • 6. Hard Surface Trenching

• Chorus approval required

• Other requirements? I.e TMP, Arborist

  Select No L2 TMP Arborist Obstruction plans required Other

  • No
  • L2 TMP
  • Arborist
  • Obstruction plans required
  • Other

• What is required?

Health, Safety and Environmental Issues

• Underfloor access?

  Yes

  No

  N/A

• Ceiling access?

  Yes

  No

  N/A

• Location of ETP?

• FTP location photo

  Media

• Dogs on site?

  Yes

  No

  N/A

Internal information

• Location of ONT?

• ONT location Photo

  Media

Additional job instructions

• Detailed description of works- If required

• Add labelled photos using the 'inote HD' app

  Media

Consents Required

• Right of way?

  Yes

  No

  N/A

• Multi dwelling unit?

  Yes

  No

  N/A

• Heritage site or Building?

  Yes

  No

  N/A

Additional notes

• Notes

Outside property consent - Boundary to ETP

• Hole excavation and trenching?

  Yes

  No

  N/A

• Removal of concrete/tiling/pavement?

  Yes

  No

  N/A

• Installation of pipe(s)?

  Yes

  No

  N/A

• Special instructions

  Yes

  No

  N/A

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

Inside property consent

• Drilling small holes and installation of hardware ?

  Yes

  No

  N/A

• Cutting holes in walls?

  Yes

  No

  N/A

• Exposed surface wiring?

  Yes

  No

  N/A

• Others?

  Yes

  No

  N/A

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
  - If I am not the owner of the property, I have obtained the 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]

• End user signature:

  Sign