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5ullding & IICode Regulatlon Dlv1slotn
2300 Vlrgl� is Ave
Fort Plerce, FL 34982
772-462-2165 Fax 772-462.6443
Request for 30-Day Temporary Power Release
Date:5 i
— Porn71L Number
Project Addmss: _._ + 4 r
THEE UNDERSIGNED HEREBY REQUEST RELEASE OF ELECTRICAL POWER TO THE ABOVE DESCR.IOCC)
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 CONSIDERATION OF APPROVAL nF ,rPiF,
REQUEST WE HEREBY ACKNOWLEDGE AND AGREE AS FOLLOWS;
1. This teml[)O ry power release Is requested for the abova statratl Purpose Only, anti thore will be nu
occupancy Of any Lype, Other than tl'urt perrr61t(ed by con19kruction during this tlnle period,
3. As witness by our signtituret, we hereby ngr6rr to Abide by all terms and conditlnn.v of thly Agreement,
Including Building Division Polley, which Is Imorportated htiref) by reference,
3. All condltians and rcqulranlents listed Ir) the attached dQeumerIt entitled "Requi►ernonts fur .3� f)ay
Power for Testing" have bean fulfilled and the prenilsca I9 rc�acly far eompllanra IrtspQctlan,
4. All Treasons for on request,
Power
d 30 dayt rrnust 1)0 rnradra In vrriting to the Building Offle,%ji 3tatlnr�
ll�e reason for the rLquest, Power njay be removticl from the bite and/or �� Strap Work Orclor Issued if
the Final Inspection has nut been npptoved tivithln 30 clays. A tee of $IU®,W will be req(rlred to Ilft
the Stop Work Order,
WE HEREBY RELEASE AND AGREE TO HOLD HARN1l.ESS, S`r, LUL;IC C;CftJN lY, AND THEIR EMPLOYEES FROM
ALL LIABILITIES AND CLAIMS OF ANY TYPE Or NATURE WHICH MAY ARISE NOW OR IN THE FUTURE OUT
OF THIS TRANSACPION, INCLUDING ANY DAMAGE WHICH MAY BE INCURRED DUE TO THE
DISCONNECTION OF ELECTRICAL POWER IN THE EVENT OF VIOLATION OF THIS AGREEMENT,
' DATE
GENERAL CONTRACTOR SIGNATURE ��"—""""!"" """ •
GATE—__..r...�.
ELECTRICAL. CO
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