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