Application for Utility Service Termination

THIS IS NOT A PERMIT. Additional permits and inspections may be required and are the responsibility of the customer. ALL APPLICABLE FIELDS ARE REQUIRED.

This form is also available in PDF format here: Utility Service Termination

Property Owner

General Contractor/Developer

Utilities Currently Active

The undersigned accepts full responsibility for the accuracy of the information provided and for all fees and expenses. HBPW Fee Schedule is available at hollandbpw.com. Termination of services will require a minimum of ten (10) business days AFTER Holland BPW receives the form or ten (10) business days AFTER the vacancy date, whichever is the later date.