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v. Request to Energize an Electrical Installation
'i r Department of Consumer and Business Services
"' Building Codes Division• 1535 Edgewater St.NW,Salem,Oregon
'4.'"ir Phone:503-373-1268•Fax:503-378-2322
.114
Web:elregon.gov/bcd C \kl\--\ -
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REQUESTING SUPERVISING ELECTRICIAN INFORMATION }
Name of supervising electrician: Joe Squires Date of request: 2/12/21 k
Supervising electrician's license number: 4882S Date installation was completed: Z 1)'2421
Electrical permit no.: F L-6 1- dOO(ti if a temporary permit is posted at the job site,please indude a copy with this form
EMPLOYING ELECTRICAL CONTRACTOR INFORMATION
Name of electrical contractor: Squires Electric, In. License no.: 26-11 O1 C
Business address: 820 SE Washington St.
City: Portland - State: OR ZIP:
Phone: 504 25,1609 Fax: 50 2 _5831 Email: Andrew@SquiresElectric.conx
CUSTOMER INFORMATION
Customer's name: \s
Customer's address.
12285 SW Marion St.
City: Tigard State: OR ZIP: q 3
Address of installation if different than customer's address:
City: State: ZIP:
INSPECTING AUTHORITY INFORMATION
Authority having jurisdiction to inspect: City of Tigard Phone: )1 Z "5I
Address: t2 S A t ,
City: State: 0?----,,,_ ZIP: r17—d-a 3
RECEIVING ELECTRIC UTILITY INFORMATION
Name of electric lility receiving request: PGE Phone: - -
Address: -
City: - ----- State: ZIP:
REASON FOR REQUEST
A. Restoring electrical service that was interrupted or disconnected because of either a:
0 Service change or 0 Uncontrollable event,such as fire,flood,or severe weather;
or
B. Electrical service at a remote location needs to be:
❑Initialized ❑Restored
COMPLETION INSTRUCTIONS AND SIGNATURE
Supervising electrician Electrical contractor
Note:After sen g this form to the electric utility Note:By close of business on the first business day following
named above,y u lit send a copy of this form to: energizing of a completed installation in response to the above
(1)the electric I c n ractor,(2)the customer,and request,you must(1)notify the authority having jurisdiction
(3)the inspect au' ority. that the installation has been energized and(2)request that the
/1,�J�1 authority inspect the completed installation.
Supervising electri xn's igoature / Date Electric utility
Note:Please consider notifying the inspecting authority
identified in this request when an installation is energized
before inspection.
@CBS
440-0948(1/20/COM)