Correspondence May. 23. 2014 6: O1 PM PGE TCC QUAD A No. 4667 P. 1/1
• ,,i. ,,,, Request to Energize an Electrical Installation .
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..1 Jurisdiction address:••'ii,.ii, Yi
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Name of supervising electrician; _�0[3/(6'1 C A 4174 — Date of request: q /,r//
Supervising electrician's license number: 'Ti 0 s Date installation was completed: / /
Electrical permit-no.:E L 6t 4-dOZ63 If a temporary permit is posted at the job site.please include a copy of it with this form.
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Name of electrical contractor:�� o ~l ir�G T h [(- License no.: 3' ' i S�� '
Business address:7 r 7/ S'/i_ t>`D' iv c'-ry r, s /i i-'- /,4
City: /*',y tL,Ir�/) I_ Q h 9 7 'L e'( , State: p.‘, ZIP: 57 t a -
Phone: - - Fax: - E-mail:
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Customer's name: , , .. �, e _ II '
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Customer's address: 1 2_3 75 5. Gil. �u L I 9(j/d
City: l,,,, Vs State: p A ZIP: 7 7? z.3
Address of insta ation if different than customer's address:
City: _ State: ZIP: -
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Authority having jurisdiction to inspect: , ,, Phone:503 -71;- ,3 •
Address: 3 2_5 -s(W .L .: ( a a
City: ltV State: 0a, ZIP: Z
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Name of electric utility receiving request: ° . Phone: - -
Address:
City; _ State: ZIP:
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i ♦ �y t 3+f: f'I�Qi��►►•• CCQ'��Jff-sfTCCVLV'EST y� � 1 a;r'S Yh'- � Y •�73 �v.')�"?S'7-
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A. Restoring electrical service that was 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 0 Restored
:;4 , . 4:: . CO10LETIO(`t.,IN .TR00Tl0, S AIgDl ,S1GNArTURE tja::_4N;'` . :.irdl ,_ ;;}•.
Supervising electrician Electrical contractor
Please note----After sending this form to the electric Please note—By close of business on the first business
utility named above, you must send a copy of this form to: day,following energizing of a completed installation in
(1)the electrical contractor,(2)the customer, and (3) the response to the above request,you must: (1) notify the
inspecti 1 autho / authority having jurisdiction that the installation has been
energized,and (2)request that the authority inspect the
'� _ 7 �1 completed installation,
Su.er sing electrician's signature 1 Date'
grrgi OF
It; cR
A ICES _
440-0948•COM(9/03/COM