Permit Support Document Request to Energize an Electrical Installation
',Ac" � i Department of Consumer and Business Services
��`` Building Codes Division • 1535 Edgewater St, NW, Salem, Oregon
`,4 ,„/ Phone: 503-373-1268 • Fax: 503-378-2322
Web: oregon.gov/bcd
REQUESTINGGary SUPERVISING ELECTRICIAN INFORMATION
Name of supervising electrician: Arzate Date of request 3-$-21
Supervising electrician's license number: 4007S Date installation was completed: 3-5-21
l Electrical permit no.: ELC2021-00112 �
-_ LJ'n lempornry permit is poster(at the job she,please include a copy with flrtsJonrc
EMPLOYING ELECTRICAL CONTRACTOR INFORMATION
Name of electrical contractor: A&G Electric LLC License no,; C1213
Business address: 7801 NE Quarry Rd
City: La Center
I Phone: 360_624.3048 State: WA , ZIP: 98629
Email: garzate1@gmail.com r
Fa`
CUSTOMER INFORMATION
Customer's name: "C.e..e, e,7 i ttv35t vhefv' / (A f`'',s.rt `�e�e
s...iCustomer's address:8335 SW Durham Rd `-� LS
Ca
City: Tigard
_ State: ORt• g74
Address of installation if different than customer's address: � - ` r .
rI t
City: �;
_ State: - e
I PELG AUTHORITY INFORMATION " sEf
NS T IN e '
Authority having jurisdiction to inspect: City of Tigard
Address: Ph
"
one: 5E13-639.$171
i City: Tigard
State: OR gZ �
I RECEIVING ELECTRIC UTILITY INFORMATION '� y ` is 'gam 1
--- ii" ',1 Name of electric utility receiving request: Portland General Electric
Address: _ Phon e
City: -
_ State: -
REASON FOR REQUEST `
A. Restoring .7, � L electrical service that was interrupted or disconnected because of either a: �"�
❑ Service change or Uncontrollable event, such
or
h as fire, flood, or severe weather,
B. Electrical service at a remote location needs to be:
❑ Initialized ' 'r
_ ❑ Restored
COMPLETION INSTRUCTIONS AND SIGNATURE tk i ` 1 Supervising electricianr � >
Note: After sending this form to the electric utilityElectrical contractorr),..,:,iiit.-03ii4,61],cot
named above,you must send a copy of this form to: ore: lin close of business on the fast , t
energizing of a completed iy the attDti'. a 4 , 2iiii ,
(1) the electrical contractor, (2) the customer, and
request, you must: (1) notify the auto , ' =*
(3) the inspecting authority.
that the installation has been energizes a
authority inspect the completed instaltat' f
Supervis'4g electrician's sin tire--;_,tea} mite. Electric utilityCI i
.iik;,i + f Note: Please consider notifying the inspecting authority
identified in this request when an instal(a orE s>1eC. ,
a ,' P Za identified
i inspection. x .~
iDCBS
440-0948(1/20/COM) t �'
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