Permit 1ry CITY OF TIGARD ELECTRICAL PERMIT
11 : COMMUNITY DEVELOPMENT Permit#: ELC2021-00603
Date Issued: 10/25/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S1036A00800
Jurisdiction: Tigard
Site address: 11865 SW WALNUT ST
Project: McCoy Subdivision: None Lot: None
Project Description: Pump Installation
Contractor: OWNER Owner: MCCOY, MARY P
11865 SW WALNUT ST
TIGARD,OR 97223
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Pump or Irrigation Circuit 10/22/2021 $67.84
Specifics: 1 ea 12%State Surcharge- 10/22/2021 $8.14
Electrical
Type of Use: SF
Class of Work: OTR
Type of Const:
Occupancy Grp:
Total $75.98
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 throuah OAR 952-001-0090. You max obtain a cony of the rules or direct questions to OUNC by callina 503.232.1987 or 1.800.332.2344.
Issued By: I-jo-L14i Vcun.,De-Wege- Permittee Signature: 0w Apig-Ltx-a-41.4-K.
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.
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
;RESIDENIIAL::WOR ONLY: FEE SCHEDULE
Description I Qty. I Each I Total 1 *
Fee for all residential systems combined: $75.00 Renewable electrical energy systems:
Check Type of Work Involved: 5 kva or less 100.70 2
5.01 to 15 kva 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301.04 2
50.01 to 100 kva 552.26 2
❑ G• arage Door Opener* >100 kva(fee in accordance
with OAR 918-309-0040) 552.26 2
❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System*
Each additional kva over 25 7.42 3
❑ Vacuum Systems* >100 kva-no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
❑ Other: Each additional inspection is 66.25/hr
charged at an hourly(I hr min)
Inspections for which no fee is 90.00/hr
specifically listed hr min)
COMMERCIAL WORD ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system: $75.00 Subtotal(Enter on Page 1):
(SEE OAR 918-309-0000) * Number of inspections allowed per permit.
Check Type of Work Involved:
❑ A• udio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ D• ata Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
n Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
n M• edical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:\Building\Permits`ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015
RECEIVED
Property Owner Statement OCT 12 2021
CITY OF fiGARD
Regarding Construction Responsibilities BUILDING DIVISION
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:
i .
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
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.
M '< ?. M 6-Co`(
Print Name of Permit Applicant
/ 0 2 I
Signature of r it Appl ant Date
Permit#: \_C. -02-k 3...... 0
Address: \\ce..ko
+aura
Issued by: ` Vi\--VS 2A i:gs
Date: .. ........ .
This Copy for Permit Offices