Office of Building Services Page 1 of 1 BF36 Request for Main Power
Revised September 29, 2017
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Date: Permit No.
Project:
Owner:
Contractor:
We request this project be electrically energized for days for the following reasons:
We understand and agree that this facility is not to be used or occupied prior to a Certificate of Occupancy
being issued, and if Lake County should hereafter find that the facility has been occupied before a Certificate of
Occupancy has been issued, Lake County have the unilateral right to direct that the electricity be disconnected
without notice. Furthermore, we understand and agree that should Lake County exercise such right, the County
will not be responsible for any damages or costs which may result to either or both of us from the exercise of
such right. Also, in the event any third party claims that they have been damaged by the exercise of such right,
we agree to jointly or individually indemnify and hold harmless the County for all such damages and costs,
including reasonable attorney's fees.
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(FEES DUE UPON APPROVAL)
(Signature of Owner) (Signature of Contractor)
(Printed name of Owner & Title if applicable) (Printed name of Contractor)
SWORN TO AND SUBSCRIBED SWORN TO AND SUBSCRIBED
before me this day of before me this day of
20 , by , 20 , by ,
who is personally known to me or who has produced who is personally known to me or who has produced
as identification and who as identification and who
did or did not take an oath. did or did not take an oath.
Notary Public Notary Public
Building Official or his designee
click to sign
signature
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signature
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