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Report rer. Request to Energize an Electrical Installation .. REQUESTING SUPERVISING ELECTRICIAN INFORMATION Name of supervising electrician: Douglas R McCauley Date of request: '7aril Supervising electrician's license number:57r84S Date installation was completed: I�7 Electrical permit no.: ` ('Z,•[.-MO/fa a temporary permit is posted at the job site,please include a copy of it with this form. EMPLOYING ELECTRICAL'CONTRACTOR ''INFORMATION Name of electrical contractor: Moilenhauer Enterprises, Inc. DBA Mike's Electric License no.: C643 Business address: 11070 SW Allen Blvd, City: Beaverton State: OR ZIP: 97005 Phone: 503-649-6991 Fax: 503 -641-1902 E-mail: mikeselectricgmikeselectric.biz a CUSTOMER'INFORMATION Customer's name: L. d Customer's address: 0 '�(.tD ,y7u.Van l;a (,,,41 City: State: L�p�� ZIP(: a-7M Address of installation if different than customer's address: f 2g35 ) ( rAyvi. 'v" City:'" 1 1(Z/1 V',l State: , ZIP: G •n�" j J INSPECTING AUTHORITY INFORMATION Authority having jurisdiction to inspect: c4A,A -t';eci, Phone: - - Address: City: State: ZIP: RECEIVING ELECTRIC UTILITY INFORMATION Name of electric utility receiving request: t" . Phone: - - Address: City: State: ZIP: REASON FOR REQUEST:' A, Restoring electrical service th as interrupted or disconnected because of either a: ❑Service change or 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 sending this form to the electric utility Note: By close of business on the first business day following named above,you must send a copy of this form to: energizing of a completed installation in response to the above (1) a electrical contractor,(2)the customer, and request,you must: (1)notify the authority having jurisdiction (3)th in e• '8: : •• •% . t that the installation has been energized,and(2)request that the //� °' 2_7�j f authority inspect the completed installation. Supervistfig elect ' s signature J 1 Date Electric utility Note: Please consider notifying the inspecting authority identified in this request when an installation is energized before inspection. WEivra 440-0948•COM(10/08/COM