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Name of supervising electrician: c _ tj re .S '' Date of request: /1(A0/6 9
Supervising electrician's license dumber: 4-$0:4..g Date installation was completed: // j/ 09
Electrical permit no.: (fa temporary permit is posted at the Job please include a copy of it with this form.
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Name of electrical contractor: %.6 wi rem , ' ■ r; e_ License no.: c2(p ' //0 /e,
Business address b a D, L 9/
City: t State: OR ZIP; 97,79,J-.
Phone: 5 L L I1Jp9 Fax: i i . 5 4 ( E -mail: Bon .5 9t4; re6 e_ei - v- ie.. d.c»n _ _
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Customer's name: •
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Customer's address: 144,15 4.6 I.6 1 741, n--, ,i•
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City. c o2.� -. _ Sp r 1
ate :_ ZIP: '94.
Address of installation if different than customer's address: _ 7 1:
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City: , _ State: ZIP:
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� —co • � ' Phone: 543
Authority having jurisdiction to inspect: , t � � - 4/7/
Address: i &, 0 0 Acrl I 1510••
City: -- . dX a State: CI ZIP: 97
Wiikl" . ' 7 * ..., ° :. - _ g r s _rii1 : - . i .A160177".71:. . = , TAMER ± .
Name of electric utility receiving request: `� Phone , 73&- 5(t
Address: 5834 or 1 cgi, A
Cit 12) S, out-d' State: OP_ ZIP: q r7 j-.
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A. Restoring electrical service that was interrupted or disconnected because of either a:
❑ Service change or Uncontrol event, such as fire, flood, or 4vere weather;
or I I
B. Electrical service at a remote location needs to be:
❑ initialized ❑ Restored
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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) the electrical contractor, (2) the customer, and request, you must: (1) notify the authority having jurisdiction
(3) the inspecting authority, that the installation has been energized, and (2) request that the
authority inspect the completed installation.
Supervising electrician's signature Date Electric utility
O q Note: Please consider notifying the inspecting authority
1/ + identif in this request when an installation is energized
before inspect
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REQUESTING SUPIERVISING ELECTRICIAN � —
— ro INFCrRAflA71pN
Name of supervising electrician:.. (71 -( Date of request_ / / � I
Supervising electrician's license number_ S I gid s Date install a a nn was completed: L a / 3 )1 07
Electrical permit no.: Q_C t(oo9 _ (, 4, m( fa temporary permit is posted at the job ci, e.please include a copy of it writ thir form
EMPLOYING ELECTRICAL CONTRACTOR INF 7 RMATION _
Name of electrical contractor_ g. ' - , . no.: Licease — ; 9j 7) Business address_ h 5 4. %., , ! . a , 1 • - —
City: tl Qt,.. • syv-1 I ' �� St - 0 R. ZIP: : 7 - 7 t 7 _
Phone: - j - Fax: 5 S- �'7 /� pl -t� E-mail:
i CUSTOMER INFORMATION-
Customer's name; 'OOvA .
Customer's address: j 10 ' a •
City: a s A t , f 1 stall: 1O L ZIP: i' >
Address of ' • . : ;on if different than customer's address: _
City: _ Stan : r ZIP
INSPECTING AUTHORITY INFORMA7li I ial
Authority having jurisdiction to inspect tl ii, - Phone: 50 3 -1 i - f t 7(
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Address: • t
t..�
City: \ . \cd _ _state - 0� ZI1: --
RECEIVIN _ELECTRIC UTILITY INFORMt.iION
Name of electric utility receiving request P Co. Phone: Spa -�- gin
Address: -
City: - — - Slate L)?,, ZIP:
REASON FOR REQUEST
A. Restoring electrical service that was iitct:Iupted or disconnected because ofeit a r a:
0 Service change or A Uncontrollable event, such . ail flood, or seven " veather,
or 1
B. Electrical service at a remote location needs to bc:
❑ Initialized p Restored
COMPLETION INSTRUCTIONS AND SIGNf "I 'LIRE
Supervisi>,tg electrician Electrical contractor
Note: After sending this form to thc electric utility Note: By close of busine s:; on thc first business day following
flamed above, you must send a copy of this form to: energizing of a complete 1 installation in response to the above
(1) the electrical contractor, (2) the customer, and request, you Muse. (Il) no i y the authority having jurisdiction
(3) the inspecting authority. that the installation has b: :e n energized., and (2) request that the
authority inspect the corn,. eted installation.
Supervising electrician's signature D tr Electric utility
`" Note: Please consider n0 ti Eying the inspecting authority
i 41 identified m this request , v: nen an installation is energized
' t �� dui i s 13i ) IL before inspection -
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REQUESTING SUPERVISING ELECTRICIAN INF 5 RMATION
Name of supervising electrician: /ri IAN V � P� SAD e Date of request 49, '31 / n 9
. Supervising electrician's license number. , r ) pia S _ Date instaff ti i,n was completed: J 2 I3 1 U f
Electrical permit no_: PLC i( p Q - fo temporary permit is posted at throb sit t plra.,'e include a copy of it with this form.
EMPLOYING ELECTRICAL CONTRACTOR INF 7 RMAT1ON
Name of electrical contractor. vas- IN7 3 n c Lice c no.: r_-.. 9j 2)
Business address: 1.s Q, \� � -P PS D *1 s F
cit 0�1 .aor ► 1 Sta4 :: d R ZIP: 9 7 :,1
Phone: Sly -729- Sq Fax: c , m c g.g a 6 E-mail:
_ CUSTOMER INFORMATION
Customer's name: \JV
Customer's address: / 10 i • . • A -
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City - ( r r 1 Stab _ ZIP: `_ 0 /7a a
Address of ' on if different than customer's address:
City: Stav ZIP.
INSPECTING AUTHORITY INFORMATI
Authority having jurisdiction to inspect al 41 l _ Phonc: 5 u 3 - I i ? L/ 17
Address: V S vi:.. T TAM lit
City: Sta op, ZIP: 97 a 33 _
RECEIVI ELECTRIC UTILITY INFORMATION
Name of electric utility receiving request Cr7 C Phone: 503 -7 - 54S
Address:
City: Starr UV..., ZIP:
REASON FOR REQUEST
A. Restoring electrical service that was interrupted or disconnected because of eit h mr a:
❑ Service change or 121 Uncontivllablc event, such a flood, or sever c weather;
or
B. Electrical service at a remote location needs to be:
❑ Initialized _ ❑ Restored
_COMPLETION INSTRUCTIONS AND SIGN. %TURE
Supervising electrician Electrical contractor
Note: ASa sending this form to the electric utility Note: By close of busia c on the first business day following
named above, you awsl send a copy of this form to: energizing of a completl r. installation in response to the above ,
(1) the electrical eoidmdar, (2) the customer, and request, you Mist (1) n41 ify the authority bay ing jurisdiction
(3) the inspecting authority. that the installation has 1 il en energized, arid (2) request that the
authority inspect the cot Witted installation_
Supervising electrician's signature Date Electric utility _
er
Note: Please consider nn :ifying the inspecting autbnrity
r identified in this request ashen an installation is energized
/ ((,t/ 1 ) L r a l d 13 J D 7 before inspection. "-
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