Permit CITY OF TIGARD ELECTRICAL PERMIT
114
COMMUNITY DEVELOPMENT Permit#: ELC2021-00444
T f G A li D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 8/16/2021
Parcel: 1 S134ACO2658
Jurisdiction: Tigard
Site address: 11330 SW COTTONWOOD LN
Project: Hall Subdivision: ENGLEWOOD NO.3 Lot: 224
Project Description: Replace(1)200 amp or less panel.
Contractor: OWNER Owner: HALL,ANDREW J& KELLY A
11330 SW COTTONWOOD LN
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Services or Feeders-200 08/15/2021 $100.70
Specifics:
amps or less
1 ea 12%State Surcharge- 08/15/2021 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
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 OA 952-001-009 . You may obn oov of the rules or direct questions to OUNC by callino 503.232.1987 or 1.800.332.2344.
Issued By: � y�2 d� Permittee Signature: ,cC"r )/feee/ ,
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'N 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.
E - 83121
Electrical Permit ApplicatioIRECEIVE
City of Tigard Received zr P .:2/ .moo Pt.ma ir-ELG°202/-00 yyL
13125 SW Hall Blvd.,Tigani,OR 97223 AUG tJ 2021 pnr.I k.,
e Phone: 503.718.2439 Fax: 503.598.1960 Date jy' L / /�A Related Pena 0:
.t„ I] Inspection line: 503.639.4175 CITY OF TIGARD tvroufied a arBY 4/z/ „aye /7 B sae Page for
internee www.tigard-or.gov Ih Sappitaismal Information
y /Lr.t�
TYPE UF.W I PLAN REVIEW
❑New construction 1�Addition/alterationheplaceenent Pl e c cheek al I that apply(submit 2 sets of plans w/terns chocked):
❑Demolition ❑( er ['Se
rvice or feeder 400 amps or oxen ❑Building over three storms.
where the available mutt current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION r,,..is 10,000 amps at 150 volts or ❑Hunting buildings.
IS1 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less CO ground«�eeed,14,0pp ❑Ca meemol ag u mite
❑Multi-family ❑Master builder ❑Other: amps foe an other liana/Llama a. buildings.
❑Fin pump. ❑installation of 150 RYA or
JOB SFTE INFORMATION AND LOCATION ❑Emcrlicacy system. buys to eately dented
Job ft: Job site address:115305iv(J3V1"ohtVQOo\ ❑100HPoofocwono«1a.dar system
V W- ImHP or more. ❑-A","E','1-2^,"I-3",
City/State/ZIP:1(q M2d J 6 e 172.Z3 a S Health-care residentiallities
units. ❑R .l"chicle pets.
SnitrJbldgJapt#: Project name: ❑narsrtloos locmiona. ❑Supply voltage for oxen than
in ❑Service or feeder 6(n/amps or more. 600 volts nominal.
Cross street/directions to job site.216 .}p 50(^(h i 1 J vlec) b e_r _ FEE SCHEDULE
rna�te 3`a l 1 , ilo.,sre o� right-side N"end de I 0ti I Each I T.� I .
Subdivision: d gara or mn,t]I.m,y dwelling unit
Lot#: Includes attached garage.
Tax map/parcel#: I,WO sq.ft or less 168.54 4
Fa.add'1500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
�a I �'- (with above aq.R) 75.00 2
�IeIaCCVVVC_lit-f-
Limited tmsgy,multifamily
75.00 2
residential(with above eq.ft.)
PROPERTY flW[VER I Q 'IENANI•.. Renewable Energy 0 See Page 2
St7viees or feeders installation,alteration,sidles relocation
Name: K t✓I `y h• 04_1( 200 antes or less i 100.70 IOC 10 2
Address: 1 I330 Sou c'4-4o„c.0 r— , k,n . 201 amps to 400 amps • 13356 2
401 amps to 600 amps 200.34 2
City/State/ZIP: ((c(14ed1 t 02 'l1Z2.3 601 amps toi,000amps 301.04 2
Phone:(SO ,)'(1 S— ci Z1 („, Fax:(„_T_%' Over 1,000 amps orvolts 552.26 2
Temporary Email: Ke I NK i I®C,G(*)CA(S±.At.* relocation services Sr feeders Installation,alteration and/or
()weer 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,rent,or etxchange,according to ORS 447,449,670,and 701. 201 amps to400 amps 125.08 2
� _ e�
Owner signature: cal) Date:r"3-1-acii,I 401 amps to 599 amps 168.54 2
Branch new,alteration,or extension, paced
in A 'IC 0 CONTACT PERSON
A Fee fi branch circuits« fe
e,
Business name: above service feeder fee,
Contact name: each blanch circuit 7.42 2
_.._ 13.Fee for branch circuits mahout
Address: service«feeder fee,first 56.18 2
brands circuit
City/State/ZlP: Each edd'1 branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax::( ) Each manufactured or modular
Email: dwelling,a ice and/or finder 67.84 2
Reconnect only 67.84 2
CONTRACTOR Pump irrigation circle 67.84'^ «� 2
! to,,,k, 0W t�� r Y l d, !cis
sign or outline lighting 67.84 2
Burin n ,/
Ad Signal cirwil(s)or limilodata-rgy ❑ See e 2 2
ff ff t` panel,alteration,or extension.
Ci /S 1P: C 1 rf ,c d ` 1s Ft /((9 Q_yt„1 rl Each additional inspection ever aliowabk hi any of the above
11 l.- (` 1T V 1[� l,, Addaicsal inspection(1 hr min) 6625/hr
Fax:( ) Investigation(I hr min) 90.001hr
Industrial plant(I hr men) 78.18/hr
Inspections for which no fee is 90.001hl'CCB Lic.: Electrical Lic.:27 7 Suprv.Lie.: specifically listed(1s hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: I t V
Print name: Date: ❑Plan Review Required(25%of permit fee):
yI ` ((((JJ)J ////���� n State surcharge(12%ofpennhfee): IT_. d p
Authorized signature: C1,�I� + 4/4h' TOTAL PERMIT FEE: II 2.. 74
Print name: I•-.�Gk ttl I lt.l I I Date: Q'—Z Z,oZI I ��days saafter It,mnbeen.e as n�complete.
atao
•
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325(2))
This statement is required for residential building,electrical,mechanical,and plumbing permits.
Licensed architect and engineer applicants,exempt from licensing under ORS 701.010(7),need not
submit this statement.This statement will be filed with the permit.
Please check the appropriate box:
rlI own, reside in,or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
4J ,1 IJ-- HS i
Print Nam of Permit Applicant
41
Signature of P r it Applicant Date
Permit#: E1- Zo2/ — 00 LP/Li
AgeiilirAddress: l f336 SW e.[7T77)n/WI.tC» t-� tir •r,�
rtz.iv
Issued by: Date: f 1.3°