Report EZ6?0/7-0023&/
,s Request to Energize an Electrical Installation
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REQUESTING SUPERVISING ELECTRICIAN INFORMATION
Name of supervising electrician: t7z4„ ;5 you n 0)
Date of request: 5 l 6 12 01 4
Supervising electrician's license number: 3 7 93 5 Date installation was completed:qt /Zc/ 2,2 r?
Electrical permit no.: rcc so'c-OOZE t If 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: Y O wfi o) i /r r 71%C. License no.: i 7 p$g 7
Business address: qq q q 5✓ w:ts'i.f.t 5-r
City: Po r r t•t n a State: a k ZIP: '772Z5
Phone:971 -fly So S?/ Fax: - - E-mail: tl.c#p s&, y,,v,,g EttO r,4,4 4..c„i„i
CUSTOMER INFORMATION
Customer's name: /fen C c o(,,,n
Customer's address: 6 7 3 5' 5 ' t/047 U r a_ Pr
City: —7—;6 e.." p State: a g. ZIP:
Address of installation if different than customer's address:
City: State: ZIP:
INSPECTING AUTHORITY INFORMATION
Authority having jurisdiction to inspect: —11 Ga r t) Phone: 5O 3-7/P- 2 y s f
Address: 1 3/ 1 5 5 4/ Ka 11 /moi i 'C
City: —7 66,r 7 State: 0 h- ZIP: q 71 Z 3
RECEIVING ELECTRIC UTILITY INFORMATION
Name of electric utility receiving request: P6 t • Phone: $m -54,z- 4g t S
Address: I Z / 5 w 5 4 t rIo„ s'r
City: POC r 1 an D State: 0 ZIP: q 7 Z oci
REASON FOR REQUEST
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:
0 Initialized Q 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)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 S/G/a( Electric utility
Note:Please consider notifying the inspecting authority
-< — identified in this request when an installation is energized
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before inspection.
DEPARTMENT Of-
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