Permit CITY OF TIGARD ELECTRICAL PERMIT
`' s COMMUNITY DEVELOPMENT Permit#: ELC2021-00518
Date Issued: 9/28/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S102CB06801
Jurisdiction: Tigard
Site address: 10475 SW PARK ST
Project: Green Subdivision: 1992-092 PARTITION PLAT Lot: 1
Project Description: (2)branch circuits for gate and shed for outlets and lights.
Contractor: OWNER Owner: GREEN, ERIC A
10475 SW PARK ST
TIGARD,OR 97223
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
2 crt Branch Circuits wo/Purchase 09/27/2021 $63.60
Specifics: Service or Feeder
1 ea 12%State Surcharge- 09/27/2021 $7.63
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $71.23
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 coov of the rules or direct ouestions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Hot-3 Va.w De-WZJZ Permittee Signature: Ow Ap-pUccutizr-kt
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.
RECEIVED
sEp 1 2021
Electrical Permit Application -pi oFTIGARD FOR OFFICE USE ONLY
Cl,
City orr igard
"1 13123 SW Ilan Ills sl..Tigatd,0 ,
g Phone: 503,7 IS.2•139 Fax: 3 rt 9 (1
Er ,,, e- i 0
50R:5;782..12yr:1-DING DIVISI°N IR)izry,,1 ./41 xi:e., Penni'E-1,d 2,02,i-Gru.. i sr-
Man Roden
Dallis.: Itedued Perlin'n:
TIGARD Inspection Line: 503.639.4175 treads Date.14. Mr. El tier Pane 2 for
.s„ Internet: wo.wtigard.or.gos, Ntainedmethod: -I
Supplemental In for irialltm_
TYPE OF WORK PLAN REVIEW
0 New construction 0 Addition/alterationireplacement ot,,,,„c oscck all dui apply(ttibiltil I WI if plan,skiitents eheel.es1):
0 Service or re,„1,,1110 amp...14 1{10(C a 11101.1i:1V Mir strict stoltiCt 0 Denmlition 12 Other:
idlers!ale asailat4;(Joh curlew 0 Marinas J1111boan.arda,
CATECORY OF CONSTRUCTION eseecth tildlOtt amps at 15ns olts n a Fltulinki l'ittl'holt•
leo.to ground,or c seceds I 4.1.100 0 Coimnereialmse aer nohow I
0 I-and 2-finnily dwelling 0 Commercial/industrial 0 Aeeessory building
as Inr all other inotallations. haildinat
0 lslulti41mily 0 Master builder DirOilter:_cl‘rsti/O .„4-C„.'
0 Fire pomp. a Imiallatinsi of 150 KVA or
JOB SECE, INFORMATION AND LocATios al met geneyr J.:oak:in larger..Cpar.111:1:,41ClileJ
Job a Addition of now motor load of syment.0: Job site address: /GIL(75 5,-, p„,,K s 4. iinnir or more.
0 S (111,1e I%Of N:4141011141 moo, oceopaney City/State/ZIP: 'If --),„..4 C.,SC 7'7 A.2 S
Recreational vehicle parks
011ealtli.eare.fiteiliti a e.t.
,..
so
StiitelbitIVAIIII,;4: Project name: (i.h.......... 0 1 latat,l.tu.,Ith'isl km. a Sopply ilage Sr more shun
0 Setviee or feeder nol amps to mat. 6011"I',"'ai"'1.
-
Cross street/directions Its job site: (A.A.:L.4 K,il.3
FEE SCII EDUI.F.
,th..fivi.!!....1____ ___I,ijil. f ., rash ....L Tom 12,
New residential sTngle-or multi-ramify abseiling nail.
Subdivision: I Lot t1:----- Includes attached garage.
-_
1 I(41...Tati map/parcel g:
— .
Ea.:KIWI Xtiiiiq.ft.sir inniton 33.92 i
DESCRIPTION OF WORK. —
Lonitol etwrgy,ncttithaitial
75.Uu 2
(e,,,A. 4 I cji.,...c,,. 4,,, (...„.4 e_... i Stec , , ,1 4 s (with uiwyd sq.li)
r te...1 z.'"*- ''-i I"' ' t Limited energy.multi-f:tmily
t / 5i A. c lel./ e$4 tris, k12,4„e , j . 1 ,
Room aisle Etinna 11.1 C alrino
2 .,0.PROPERTY OWNER 0 TENANT C 4rc.,4,5
Services or(ceders installation,alteration,and/or reticca-tian_
Name: L C f, c C- 2110 amp.:or leas 10°,70_--
•
Address: / 201 amps 10 401)amp.: 1 I 03.5ts ILc..),-( 7.0 5rt. ci.
401 amp.hi Si(S)amp, I 200 34 1
CilyiStateZir: -r, ., „J oz. ?-7 1 5
NI I tulip,to I,000 amps :oil 5i4
IIM 2
Phone:()./$,. 1 pyY- 70/LI Fax:( ) ()ter Loon ainp.or s°Ilk .3 .2,3 2
Temporary services or feeders ituttallailan.alteration.ululfor
Email: vf:t' i'l.a..,„ C: 'cc,c L't• )el 4,i i • L;(./1."-- relocation
Owner installation:Titi s (at ion is being niadc on property that I own which is not 2t111 amps or less 3936 1
intended air sale,lease r in r xeltange.according to ORS 4.17 449.67A) and 701. 20I atop.to 400 amps 125 OS 2
Owner sitmature: ' Date: 1-40-b.... 1 .10 tItups to fo)9 ampi I 16S 54 s
„...
-- _ .___
A.PPLI cAsr —T---3::jq.:0:qTACT PERSON ranch eircuit1.-ill.W alterati5 n.or estenslon,tier pane)
, A Fee for br.utelt cinaiiu frh —
ilusiness name:
ahose service or feed,'1-,,,,, -,,
7 42
:
, cacti titatidi citcuit
e- 6:
"..... -
Contact name: G/". c.- ./.<c-i- Id l's,•c fur hooch circuits twit/tor
st.lt ICC sir li.Vskr rce,Gal
AddrCSS: /4.,./7.S" c,C.,.' fc,oc* $4 Inane!,circuit ,
36 I S 2
City/State/ZIP: -7" ,/s 4 ,..,/ C.)./C r-7 i) a 3 iiadi Ain branch circuit { 7.42 -
Miscellaneous tiers ice or feeder not hie/tided)
Pit011e:(s....,4) cy,),-4, - 7c.,/ t-/ Fax::1 1 Fad,manoracturcd Or modular ,
67.S4 -
slis Any.,ers ice milts('("ceder 1 Email: t'• ca.„,,..q_ 0._,5 /,t,t... , ". _....-
Reconnect only .67.s4
CONTRAcTOR
Mittm trr imeations cirele (17,7:4
litisiti 2
4 .. . --- -----.----- ---„-
/em;nam j e: I")/,'''''' Sisti"I-ottlink:lightmg
_
.......—...,., --....... 67.S4
._
Stew!oresotild or limiteslontertty
Address:
_panel:nheration.or odension. a See Page 2 -
City/Suite/ZIP: Inch additional inspection over allonathle in:Inv of the above
Additional impection(1 lir min) 156.23.hr
Phone:( ) i Fax:( ) In‘rmiption(I hr mint — 9o.151 hr
Email: Itultbarial plant(I br min) 75.I5 hi
.,. , — lospectiotur for which no fee is
i 9.0.0W In
CCU Lie.: LElectrical Lie.: Suprv.L fica ie.: ipucillv d r liste ,lit min) - —
ELECTRICAL PERXIIT FEES
__..
Supry.Electrician sitmatute,required:
Subtotal:
Print name: Date: 0 Plan Review Required(25.!..1 of iscrotit fee):
...
---,
State surcharge(12%olpeosnit fcc):
,,//7 / 9.,
Authorized signature: ‘t"..-- /1..../s/C-A-z-N--- TOTAL PERM rl'l'Iiii: 7 1, 2--;
1 This permit esplrsus vr ins If 0,periolidls as Ind untied:led oithIn Intl
I Print name: r• -L A 6..(s,e/1 Date:c) n)c/ - 1,...,:ie
„.._
• •ClIttlInl 41111mpection.:Moo...,put Nona I inaltionrrottnisid.r.yonsttAml.i.n_l to 4,Ite,sUo 17:011 4111.46151111,01 CI sit sills
RECEIVED
Property Owner Statement SEP 07 2021
Regarding Construction ResponsibilitiesB CITY OF oiv s oN
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:
I 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.
A..-C Vi -'rCAA...
Print N- 'tee o'Permit Applicant
g_ a1, s.-mac
Signature .f Permit Applicant Date
Permit#: L t:.('� Z l 2 f -00 (cf) •T�
Address: `01 7� S vJ P i2/1- s 7— •?A 4Issued by: Date:
i,iiir
=i=
This Copy for Permit Offices
I
RECEIVED
' '' Information Notice to Owners About SEP r5 2027
` Construction Responsibilities c'1OFTIIvGAFt;
UILDfNG DIV15I9R
s�`'�� (ORS 701.325 (3))
r:r-f
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure,can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503-378-4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503-947-1488.
• Oregon's Business Identification Number(BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax.To file for a BIN, go online to the Oregon Business
Registry. For questions, call 503-945-8091.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 800-452-0288.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, go online to www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance:As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough-in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
PO Box 14140,Salem,OR 97309-5052
Telephone:503-378-4621 —Fax:503-373-2007
Website Address:www.oregon,gov/ccb
f/property_owner adopted 9-2016 This Copy for Permit