JL_Test – Tillamook People's Utility District

Request to Energize an Electrical Installation

Requesting Supervising Electrician Information

Name of Supervising Electrician*

Supervising Electrician's License Number*

Electrical Permit No.*

Date of Request

Date Installation Was Completed

Employing Electrical Contractor Information

Name of Electrical Contractor*

License No.*

Business Address*

Street Address City State Zip Code

Daytime Phone*

Email

Customer Information

Customer's Name*

Mailing Address

Street Address Address Line 2 City State ZIP Code

Daytime Phone

Email

Service Address if Other Than Above

Street Address City State ZIP Code

Inspecting Authority Information

If Other Than Above

Street Address City State ZIP Code

Temporary Service?*

No
Yes
Overhead
Underground

Date Desired

Permanent Service?*

No
Yes
Overhead
Underground

Date Desired

Contractor Information

Name

Mailing Address

Same as previous

Street Address Address Line 2 City State ZIP Code

Daytime Phone

Cell Phone

Contact Information

Address

Same as previous

Street Address Address Line 2 City State ZIP Code

Daytime Phone

Cell Phone

Project Information

Street Address & City

Same as previous

Street Address Address Line 2 City State ZIP Code

Parcel Number

(Example: 2N 10 29AC 1400)

Directions to Project (Cross Street, Mile Post, etc)

Who Will Trench, Install, Conduit, And Backfill?

Applicant
Contractor

Contractor Name

Contractor Cell Phone

Electrical Load Information

Main Breaker Size (in Amps)*

Total Square Footage*

Voltage

120/240, 3-wire, 1Ø
Other

Standard residential loads (Lighting, refrigerator, freezer, dishwasher, washer)

Air Conditioner

Tons:

Domestic Water Pump

HP:

Heat Pump

Tons:

Other Electric Heat

Add Electric Appliances

Range/Oven
Clothes Dryer
water Heater
Spa
Other

Additional Comments

Written or verbal authorization from the property owner is required if the applicant is a representative and not the legal property owner. Written authorization may be submitted by uploading a copy of the contract between applicant and property owner. Alternatively, the property owner may contact Tillamook PUD Engineering Department at 503-815-8629 to verbally authorize applicant’s request.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 100 MB, Max. files: 5.

Full Name (Customer's Electronic Signature)*

Do you consent to signing this document electronically?*

Yes

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Request to Energize an Electrical Installation

Request to Energize an Electrical Installation

Requesting Supervising Electrician Information

Employing Electrical Contractor Information

Customer Information

Inspecting Authority Information

Contractor Information

Contact Information

Project Information

Electrical Load Information