Permit CITY OF TIGARD ELECTRICAL PERMIT
1111 COMMUNITY DEVELOPMENT Permit#: ELC2021-00300
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 6!2l2021
F I C A It D 9 Parcel: 2S103CB00200
Jurisdiction: Tigard
Site address: 13065 SW 121ST AVE
Project: Johnson Subdivision: WILLAMETTE Lot: 2
Project Description: Change meter location.New entrance panel and sub panel
Contractor: OWNER Owner: JOHNSON, SARA ROSE
13695 SW 118TH CT
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
2 ea Services or Feeders-200 06/02/2021 $201.40
Specifics: amps or less
1 ea 12%State Surcharge- 06/02/2021 $24.17
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $225.57
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1,800,332.2344.
Issued By: t o-]y Vcc41'De,Wege Permittee Signature: 0 VI/App1
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale,lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m.for the next available Inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Application_ t)I t 1�t oil I( 1 1 NE O"I \
City of Tigard RECEIVED may: (0\1-1Z\ ) Peal*#:e _Ion-oo3oa
13125 SW Hall Blvd.,Tigard,OR 97223 plan Review
C Phone: 503.718.2439 Fax: 503.598.1960 .: 2021 Date/By: Related Permit#:
1 I i3 A R n Inspection Line: 503.639.4175 Ready Date/By: ram: laSee Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WOSti1I Di% DIVISION PLAN REVIEW
❑New construction Et'Addition/alteration/replacement Please check all that apply(submit 2 sets ofpiens w/items checked):
❑Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION - exceeds 10,000 amps at 150 volts or ❑Floating buildings.
Nrl-and 2-family dwelling ElCommercial/industrial El Accessory building tee fo RTO10d Of° °14,000 Cl Commercial—use agricultural
amps for all other installations. buildings.
❑M ulti-family ❑Master builder ❑Other: ❑Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION O Emergency system. larger separately derived
Job#: Job site address: 17U(,,S SW ❑Additi000foeat motor load of "Alen
2 \ Z}Sfi �t'� 100HP or room. ❑"A" "E""1-2""1-3"
City/State/ZIP: 1-1)
r t ` t ct q-2 2 -J ❑Six or more residential nails. R occupancy.
4�rA ❑Healthcare facilities. ❑Rarestloml vehicle parks.
Suite/bldg./apt.#: .y t Project name: G lvyl t`1 L. tJ a 9',/fAt)•-t-
0 Hazardous locations. 0 Supply voltage for more than
Cl Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: Cal tkav kQ — 12 15 - — 4v kw5 e FEE SCHEDULE
Dacriptioa I Qty. I Each I Total I •
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential 75.00 2
fa 1 { (with above sq.ft.)
l �61911 i+ Y'f1'etty `0(l tl S1/1/ it'd' ',Jr"CAI - 't,)e 1,..:) e v1"-6vini-k Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
,w11.l A L`a C"'h 4V-'`Y`e, Renewable Energy ❑ See Page 2 .
]'PROPERTY OWNER I 0 TENANT Services or feeders Insfallationialteradon,and/or relocation
Name: (--- Jhva Qc>.a 1-0 `. 1 200 amps or less 2_, 100.70 Z61.80 2 201 amps to 400 amps 133.56 2
Address: 1? (0 AS Strs it tf•I"lt t3 . .S(,(,,,I ..Is S \
� 1 401 snips to 600 amps 200.34 2
City/Stale/ZIP: T t y w(A s al Gll"Z23 601 amps to 1,000 amps 301.04 2
Phone:(5117)) V o143..2... Fax:( ) Over 1,000 amps or volts 552.26 2
/� Temporary services or feeders installation,alteration,and/or
Email:
(AV A (2-Ilse 0 V. 1Y1 la tC YYl ore , (.on.'1 relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 I
intended for sale,lease, or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: S)Za 12 i 401 amps to 599 amps 168.54 2
Y" APPLICANT al CONTACT PERSON Branch circuits-new,alteration,or extension, l er panel
_ n. A.Fee for branch circuits with
Business name: � a.r,_YA,E/ above service or feeder fee, 7.42 2
each branch circuit
--------- -
Contact name: B.Fee for brunch circuits without
Address: service or feeder fee,fast 56.18 2
branch circuit
City/State/ZIP: Each add'I branch circuit 7.42 2
Fax: : Miscellaneous(service or feeder not included)
Phone:( ) I ( ) Each manufactured or modular
welling,service and/or feeder 67.84 2
d
Email: _, Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: 42..c,( Li\,);'1r„k. Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy 0 See Page 2 2
Address: panel,alteration,or extension.
City/StaterLlP. Each additional inspection over allowable In any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90 00/hr
CCB Lie.: Electrical Lie.: Suprv.Lic: specifically listed(1/r hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: Z.01 01
Print name: Date: ❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE: 2.0 10'lO
This permit application expires if a permit is sot obtained within 180
Print name: Date: days after It has been accepted as complete.
• Number of inspections allowed per permit.
r.tnuiIdm61Permilst C_PetmilApp_F.LP_PRP..doc Rev 06/17/2015 404615T(Is/OS/COM/WEB