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GLENIIIE
BUILDING SAFETY DEPARTMENT
i
TEMPORARY POWER REQUEST AND AGREEMENT
PROJECT ADDRESS: S lv (J 2 Z DATE: "-Z 7 L/_°5--
PERMIT NO. i sa PROJECT NAME: / {'\-sL �(� � S�pJ- z-
A request is heruby made to the Building Official for an approval which will allow the public
utility company to connect their wiring to the electrical system of the above project until (date)
with refundable /e01- 6'c'deposit for the purpose of:
It is understood by those who sign this Temporary Power Request and Agreement that:
1. THE ELECTRICAL SYSTEM WILL BE DISCONNECTED ON THE DATE STATED •
unless the final electrical clearance has been issued, and
2. THE BUILDING OR SPACE SHALL NOT BE USED OR OCCUPIED before the final
electrical clearance has been issued.
CONTRACTOR: 7/Iii 4r.r/-5°A) PHONE NO.(OZ- 7 'c-7yjj
(PLEASE PRIN
Address: 6,6/ ° N' �0 K - P4i(SL. ./1 z 6. �1 S
Signature:
OWNER/TENANT: r:4.� i Lr 0 h PHONE NO. Z 3-z93-6)I 2)'
(PLEASE PRINT)
Address: .5,35 o 1.,) e'P 61 Sv s -,---2 I Z Z
Signature: -_,___ __--r . ��
ELECTRICAL CONTRACTOR: ile-Z u/lJ (Kt.. KCZ Z-7 PHONE NO.&O,.7 "Fs/p
-7O
(PLEASE PRINT)
Address: 7 - 3
Signature.
BL012.0
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