HomeMy WebLinkAboutPermit Electrical 2009-2-16
Request to Energize an Electrical Installation
Jurisdiction address:
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Name of supervising electrician: Ucrll'f' ~ {'':'''J7rkP Date ofrequest: d 11"/ Or I
Supervising electrician's license number: 4 'lr Cf S Date installation was completed: :l / /(J oC{ I
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Electlical permit no.: If a temporary pei'lI1it is posted at [he job site, please i/;clude a copy of il with lhis form.
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Nameofelectncalcontr)l3tor r:. d- 5 [/ecir/c ~c... . Licenseno.:drJ-J/.jC-- I
BUSiness adchess r ~ f{~);r / V ~d- . / I
City C;1'70M~/I) Slate tJ(( ZIP 77'177 I
Phone: t,'II- .J;;)7Y3k- Pax :;V/- d'173' E-inail:, I
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Customer's name: CXH7d i ~Ik, s ". I
CuslOmer's address: l' ~75(J,7; 1"; () / ~ ~ I
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Address of i,{stalIatidn if differ~nt thai'; customer's address:
City: State: ZIP:
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Cily: ~r-j;/: Slate: ZIP: I
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Name of electric utility receiving ~'eguest: .S' /(~ Phone:,~
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City: ( State: ZIP: ". I
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A. Restoring electrical sen,'i~'that was.interrupted. or disconnected because of either a:
o Service change or ncontrollablc evJnt: s"uch as fIre, flood, ~r severe 'weather;
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or ......
B. Electrical service at a remote location needs to be: .
o Initialized 0 Restored
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Supervising electrician Electrical contractor
Plc"ase note - After sending thi~ form to the electric Please note - By close of business on the first business
utility named above, you must send a copy of lhis form to: day, following energizing of a completed installation in
(I) the electrical contraclOr, (2) ti,e customer, and (3) the' response to the above request, you must: (1) notify the
inspecting aUlhority ~ (L'. .' authority having jurisdiction that the installation has been
\'--. ""'f"),- n , . "'_ /( _/1IJ energized, and (2) request that the authority illspeclthe
,\ )~ ':~ . \,;l. d 10 (/1 completed installation.
I Supervising electriCian's si~nature. Date -
Address:
rt~ DEPARTMENT OF
:>'J!l CONSUMER
,,~ >:' ..BUSINESS
IIlIi \ySERVICES
440.0948.COM (9/0S/COM