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Building & Code Regulation.Division
ia 2300 Virginia Ave
• Fort Pierce, FL 34982 ,
I� 772-462-2165 fax 772-462-6443
Request for 30-Day,Temporary Power Release
.Date: 0� Ot Permit Num er: 19(6— 0
Project Address: a 2'3_?? Y-6c S
THE-UNDERSIGNED HEREBY.REQUEST RELEASE OF ELECTRICAL.POWER TO THE ABOVE QfSCRIBFD
PROPERTY, FOR A PERIOD NOT TO EXCEED THIRTY(30) DAYS, FOR THE PURPOSE OF TESTING SYSTEMS
AND'EQUIPMENT IN PREPARATION FOR A FINAL INSPECTION. IN CONSiDERA1TON OF APPROVAL OF THE
REQUEST WE HEREBY ACKNOWLEDGE AND AGREE.AS FOLLOWS:
1_ This temporary power release is requested for the above stated purpose only,and there will be no
occupancy of any type, other than that permitted by constricaon during this time,period.
2. As witness by our signatures,we hereby agree to abide by all terms.nd conditions of this agreement,
including Building Division Policy,which is incorporated herein by refueace. ,
3. All conditions and requirements listed in the attached docurnent entitled"Requirements for 30 Day,
Power for Testing"`have been fulfilled and the premisq is'ready for compliance inspection.
4. All requests for an extension beyond 30 days must be made in writing to the Building Official stating
the reason for the request. Power may be removed from the sfte anc';or a Stop Work Order issued if
the Final Inspection has not been approved within 30 day:. A fee of$i 00.00 will be required to lift
the Stop Work Order.
WE HEREBY RELEASE AND AGREE TO HOLD HARMLESS,ST.WC7E COUNTY, AND THEIR EMPLOYEES FROM :
ALL LIABILITIES AND CLAIMS OF ANY TYPE OF NATURE WHICH MAY ARSE NOW OR IN THE-FUTURE OUT
OF THIS TRANSACTION, INCLUDING ANY DAMAGE WHICH MAY BE INCUP.F.ED G'!E TO THE
DISCONNECTION OF ELECTRICAL POWER IN THE EVENT OF VIOLATION :)F THIN AGREEIVIENT1 . -
A � b \
OWNE SIGNATURE �. DATE
GENERAL CONTRACTOR SIGNATURE r DATE
iZ�/
ELECTRICAL CONMCTO G
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