National Fuel Gas Application for Encroachment

Please complete the following application and return with the information as indicated. This information will assist National Fuel Gas Company, and its affiliates or subsidiaries, (“National Fuel”) in determining if the proposed encroachment will be allowed in the vicinity of National Fuel’s facilities. If allowable, an Encroachment Agreement between National Fuel and the Applicant may be required. As part of the Encroachment Agreement requirements, National Fuel must be named as an additional insured on the Applicant’s Commercial General Liability and Commercial Umbrella Liability Insurance, Business Automobile Liability and Commercial Umbrella Liability Insurance, and Workers’ Compensation and Employer’s Liability Insurance with the appropriate limits as specified in the Encroachment Agreement. Prior to the execution of the Encroachment Agreement, you must provide proof of insurance acceptable to National Fuel and you may be required to make a payment to cover administrative expenses.

No work on National Fuel’s right of way may proceed until Applicant is in receipt of a fully executed Encroachment Agreement from National Fuel’s Land Department. No verbal approvals are granted or implied.

Name of Applicant:

(Exact name to be shown on Encroachment Agreement)

IndividualCorporationMunicipalityOther

Applicant's Mailing Address:

Send Document to:

(If different than Applicant's address)

Location of Encroachment

Name of Landowner over which encroachment is applied:

Distance from a Public Highway:

(Name / Number)

If encroachment is to be located within confines of Dedicated Highway an encroachment agreement may not be required.

Type of Encroachment

Water Line

Sewer Line

Electric Line

Phone Line

Gas Line

Cable Line

Roadway

Other

YesNo

*required

Open CutBoreOther

Please send completed application to:

1. Review Specifications

2. Proper name and mailing address of Individual/Company

3. Location data

4. Exhibit (no larger than 11in x 17in) with GPS coordinates, Municipality, County, State and Parcel ID# listed

5. Depth of bury

6. Method of installation

7. Distance from Public Highway

8. Tax parcel number

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