Permit IN CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2021-00644
Date Issued: 11/16/2021
T I(I A R n 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 1 S136CD00101
Jurisdiction: Tigard
Site address: 11675 SW PACIFIC HWY
Project: AFC Subdivision: None Lot: None
Project Description: Branch circuit&one x-ray feeder.
Contractor: MICHAEL A WRENN Owner: COLUMBIA STATE BANK
PO BOX 86306 PO BOX 2156 MS 3300
PORTLAND,OR 97286 TACOMA,WA 98401
PHONE:
PHONE: 503-680-8800
FAX: 503-785-0765
FEES
Quantity Description Date Amount
1 ea Services or Feeders-200 11/16/2021 $100,70
Specifics: amps or less
42 crt Branch Circuits w/Purchase 11/16/2021 $311.64
Type of Use: COM Service or Feeder
Class of Work: ALT 1 ea Plan Review Electricial 11/16/2021 $103.09
Type of Const: 1 ea Info Process/Archiving-Lg 11/16/2021 $2.00
Occupancy Grp: $2,00(over 11x17)
1 ea 12%State Surcharge- 11/16/2021 $49.48
Electrical
Total $566.91
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
i 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 may obtain a coo,/of the rules or direct auestions to OUNC by callina 503.232.1987 or 1.800.332.2344.
Issued By: F(o{(y Va w De Wege Permittee Signature: Ot` A�
1
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale,lease or rent.
l
OWNER'S SIGNATURE: Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC'N Date:
LICENSE NO.
I 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.
I
Electrical Permit Applicati
EEIVED << l OR ol11 I: i. i.:O,I.v -113 � 1
(3
City of Tigard Date/By: ' Permit#: e u-00 6414
III q 13125 SW Hall Blvd.,Tigard,OR 97223 Nov 3 2r Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: 1 11 Related Permit#: P -U'Qu` (p
Inspection Line: 503.639.4175 tIly OF 1 IG n b� ' :dy Date/B �� ® See Page 2 for
1 I CI A R I) Internet: www.ti and-or. ov L7/1fl ,d
g g �,� M•` , , ler � Supplemental Information
It i . . ✓///%ate i//S/, �
TYPE OF WO'l7 ' ' ' w r 1 PLAN REVIEW
El-New construction ❑Addition/alteration/replacement Please check all that apply(submit 2 scts of plans wiitems checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ 1-and 2-family dwelling a-Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
Multi-family El Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
❑Addition of new motor load of system.
Job#: I Job site address: I r 6 75- sty P .i t--re. HW I00HP or more. ❑"A","E","t-2","1-3",
City/State/ZIP:-7 7 €r L 04. 97 L�3 ❑Six Ito more residential units. Recreational
occupancy.
.[�1- care-care facilities. ❑Rro vehicle parks.
Suite/bldg./apt.#: I Project name: AlMe r,ew, ,/y are V' 0 Hazardous locations. 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: pr,,c,hG , FEE SCHEDULE
s Description l Qty. I Each l 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'I 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
/� f" 1-1'
(with above sq.ft.) 75.00 2
�1 rL�'/v�k IO � 4- Dile n 'N4}� �� �� ��ew`J am.�j Limited energy,multi-family 75.00 2
K-( �. !� .t L/+..�, N e r,11,t r(' "0. iS 1:�p 26[.`_ n o z2_(C'/ is,),,a 19./ residential(with above sq.ft.)
r Renewable Energy 0 See Page 2
0 PROPERTY OWNER 0 TENANT Services or feeders installation,alteration,and/or relocation
Name: 200 amps or less r` 100.70 iff1A.V. 2
Address: 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP: 601 amps to 1,000 amps 301.04 2
Phone:( ) Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
0 APPLICANT I IQ CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: /V Au, O G p-��e C.47Z t c_ above service or feeder fee, 7.42 3l�/r 2
eac�` S.
Feeh obranch circuit
Contact name: IAA ` 6� B. for branch circuits without
(�{ service or feeder fee,first
Address: p,D t e b to 3OGj branch circuit 56.18 2
City/State/ZIP: a�.�l vva� , q 7 Each add'I branch circuit 7.42 2
1 Miscellaneous(service or feeder not included)
Phone:(57)3 ) 2 JC1 _..s7 -3 c 1 Fax: :�3 ) 7gs 07 65— Each manufactured or modular
( dwelling,service and/or feeder
Email: Mot fit 67.84 2
6) /na4 Jco'e[/e c_hti c.• C.CJv✓l
Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Mew ew Co £tl a C/x ic_ Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy
Address: 7 0 See Page 2 2
&� �Gy i�� panel,alteration,or extension.
City/State/ZIP: (p�C✓ CZ� Each additional inspection over allowable in any of the above
r 1 1�'w r77� 9 Additional inspection(1 hr min) 66.25/hr
Phone:( 2)3) /67_3-5-3 f Fax:(sys) 78 0 7 ,5- Investigation(1 hr min) 90.00/hr
Industrial plant(1 hr min) 78.18/hr
Email: +( r^y^ 1 l p rt,/cp ei t'_E-F+Z t G tcoInspections for which no fee is 90.00/hr
CCB Lie.: '7 2.2 L Electrical Lic.: C/b/6, Suprv.Lic.: ygio S specifically listed(%2 hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician^ signature,required: Subtotal: 7 s'Z,,3
Print name: eia is Date: //7L4/ 0 Plan Review Required(25%of permit fee): J 07,01
State surcharge(12%of permit fee): �f
TOTAL PERMIT FEE: 1 qt q,
Authorized signature:
This permit application expires if a permit is not obtained within 180
Print name: 0/4, 444,S Date: A/2—A/ days after it has been accepted as complete.
' Number of inspections allowed per permit.
is\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(I1/05/COM/WEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE
Description I Qty. I Each I Total I *
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
n Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
n Burglar Alarm 25.01 to 50 kva 301.04 2
50.01 to 100 kva 552.26 2
C Garage Door Opener* >100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System* Each additional kva over 25 7.42 3
n Vacuum Systems* >100 kva—no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
E Other: Each additional inspection is 66.25/hr 1
charged at an hourly(1 hr min)
Inspections for which no fee is 90.00/hr
specifically listed(A hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Subtotal(Enter on Page I):
Fee for each commercial system: $75.00 * Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
n Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
InBuilding,Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015