Report EL.,G 2 0 2 2--000
4. Request to Energize an Electrical Installation
Department of Consumer and Business Services
j Building Codes Division• 1535 Edgewater St. NW,Salem Oregon
Phone:503-373-1268•Fax:503-378-2322
Web:oregvn.guvRx:d
REQUESTING SUPERVISING ELECTRICIAN INFORMATION
Name of supervising electrician: Joe Squires —'� Date of reequest: 1/12/22
Supervising electrician's license nwnbcr:4882S Date installation was completed: 1/12/22
Ilectrical permit no.: ELC2022-00016 Ito ltayrararr permit is pei1ed l the job site,pltaze indade a cozy ride this fond
EMPLOYING ELECTRICAL CONTRACTOR INFORMATION
Name of electrical contractor: Squires Electric, Inc. License no.: 26-1101 C
Business address:820 SE Washington St.
City: Portland Statc:OR ZIP:97214
Phone: 50 -32 -521609 Fax: 50 -32 -535831 hmail: Andrew@SquiresElectric.com
CUSTOMER INFORMATION
Customer's name: ( cij S
Customer's address:11200SW Greenburg Rd. #28
Cite: Tigard State:OR ZIP:97223
Address of installation if different than customer's address:
City: State: ZIP:
INSPECTING AUTHORITY INFORMATION
Authority having jurisdiction to inspect:City of Tigard Phone: - -
Address:
City: State: ZIP:
RECEIVING ELECTRIC UTILITY INFORMATION
Name of electric utility receiving request: PGE I'honc: - -
Address:
City: State: ZIP:
REASON FOR REQUEST
A. Restoring electrical service t was interrupted or disconnected because of either a:
Service change or BrUncontrollable event,such as fire,flood,or severe weather,
or
B. Electrical service at a remote location needs to be:
❑Initialized ID Restored
COMPLETION INSTRUCTIONS AND SIGNATURE
Supervising electrician! Electrical contractor
Note:After sending thi form to the electric utility Note:By close of business on the first business day following
named above,you mu send a copy of this form to: energizing of a completed installation in response to the above
(1)the electrical contr• •tor,(2)the customer,and request,you must:(1)notify,the authority having jurisdiction
(3)the inspecting autl rity— that the installation has been energized and(2)request that the
1 i 1 /72 authority inspect the completer installation.
Supervising electrician.signature Mite Electric utility
Note:Please consider notilying the inspecting authority
identified in this request when an installation is energized
before inspection.
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