Permit -
Electrical Permit Application ' �� 1 OR OFFICE USE ONLY Q
Received//,, Tin permit#: W2 Z-000C>1
7,1 City of Tigard DanRevie �' ZB� /f
• 13125 SW Hall Blvd.,Tigard,OR 97223 JAN 5 7Qp7 Plan Rev ew / ^ I iY,yY Related Permit#:
Phone: 503.718 2439 Fax: 503.598.1960 Date/By: ,,_ ,/ /
Inspection Line: 503.639.4175 V , 1(: i" t ; Ready Date t �� Sari ® See Page 2 for
Notified/Method. .", 1 11�' Supplemental In form ation
TIGARD., Internet: www.tigard-or.gov 4
�� TYPE OF WORK " ` r1 FL.tt PLAN REVIEW
Ni ��l e Check all that apply(submit 2 sets of plans w/items checked)
❑New construction l� Addition/alteration/replacement t Service or feeder 400 amps or more ❑Building over three stories.
❑ Demolition ❑Other: T where the available fault cuaent 0 Marinas and boatyards.
• CATEC I2Y OF CONSTRUCTION V exceeds 10,000 amps at 150 volts or ❑Floating buildings.
ess to ground,or exceeds 14,000 0 Commercial-use agricultural
❑ 1-and 2-family dwelling <�C Commercial/industrial ❑Access Accessory building amps for all other installations. buildings.
b ❑ Multi-family ❑Master builder ❑Other: ❑Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived
0 Addition of new motor load of system.
Job 4: Job site address: a 1634 SSu.) p as-it(, kwu5 IOOHP or more. ❑"A","E"•"1-2","I-3",
f M ❑Six or more residential units. occupancy.
l l •City/State/ZIP: T I yi r({. V k 1122 3 ❑Six more facilities. ❑Recreational vehicle parks.
J ❑Supply voltage for more than
Suite/bldg./apt.#: Project name: Mike$ r I et �❑Hazardous locations.
" t V C. ❑Service or feeder 600 amps or more. 600 volts nominal.
Ir Cross street/directions to job site: Su) 14 T,n a, I?-gctei U t T. Ot FEE SCHEDULE
tJ rVl Description 1 Qty. 1 FIxri I Total
k. New residential single-or multi-family dwelling unit.
Subdivision:
Lot#: ,_Includes attached garage.
1,000 sq.ft or less 168.54 4
Fax map/parcel#: y Ea.add'1500 sq.ft.or portion 33.92 1
F DESCRIPTION OF WORK U „ _ - 4 Limited energy,residential 75.00 2
"c �t�-f 1 - (with above sq.ft.)
S l CR. ✓'Ot Vd' '—�m`�'�e' Limited energy,multi-family •
75.00 2
residential(with above sq.ft.)
1 Renewable Energy ❑ See Page 2
❑;YKOPERTY,OWNER,.. TENANT �! ces or feeders installation,alteration,and/or relocation
Name: ��e�Dy` ` rq IO 0ampsorless 100.70 2
L A 201 amps to 400 amps 133.56 2
Address: 5 2 S M at Cady 1,Je . 01 amps to 600 amps 200.34 2
City/State/ZIP: Po r-i la,vl A, , all_ 5-72._G9 ,4 601 amps to 1,000 amps 301.04 2
Phone:(31'I, ) 2SL- 5 152 I Fax:( ) N Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: /'G4 I i$ r I c�j" ' IMctl I . Conn relocation
AOwner installation: This`installation 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
rx Branch circuits—new,alteration,or extension,per panel
�API'LICANT -: I. ❑ CONTACT PERSON A.Fee for branch circuits with
it Business name: O IU E LC CT 21c Li.—C above service or feeder fee, 7.42 2
each branch circuit
Contact name: 1� t„t ST O N Sc.1-1 a ►.)K. B.Fee for branch circuits without S�I )
service or feeder fee,first ' I 56.1 B 2
Address: C%1 Lo S w 1.4 ILL MAN CT STE S IS branch circuit
Each add'l branch circuit W� 7.42 3L ) 2
City/State/ZIP: W )Lro V IL{f l 0 R 91 0-IQ Miscellaneous(service or feeder not included)
Phone: l { - Z'�y 5 I Fax: ( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: duc�i.0yt� Qh ' L'-IL'f,'i"V'IC,£Ci''h Reconnect only 67.84 2
_ CONTRACTOR : Pump or irrigation circle 67.84 2
Business name: 1 n, ( /tl it ) , Q/ Sign or outline lighting 67.84 2
G y � YYY tt' `'^�`� Signal circuit(a)or limited-energy
Address: q-72 U s Y V i l I 1„a,n ct S'tj o IS panel,alteration,or extension. ❑ See Page 2 `16 2
ty V V I It il 4 11 Pi l et-zip Each additional inspection over allowable in any of the above
City/State/ZIP: �]p� Additional inspection I hr min 66.25/hr
Phone: 455 yrtt�611_ Fax:(j)054 2OZ • Investigation(1 hr min) 90.00/hr
v v Industrial plant(I hr min) 78.18/hr
Email fiNr'- 0 on-.61 eeh4(, .am . Inspections for which no fee is 90.00/hr
CCB Lic. O5 f 00 Electrical Lie.:/'I fr $l Suprv.Lic.: cz specifically listed(%:hr min)
vj . ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: n • Subtotal: L 9
ffli
Print name: Date:
❑Plan Review Required(25%of permit fee): "
State surcharge(12%of permit fee): �'-
22-
g ) L1 1---
. TOTAL PERMIT FEE: /
Authorized signature: `) This permit application expires if a permit is not obtained within 180
Print name: it: :::y. Date: days after it has been accepted as cam lete.
* Number of inspections allowed per permit. 6 / Q�
1aBudding1PermitsrELL PenniiApp_ELR_EISE_doc Rev 06/17/2015 ' 440-4615T(I1/05/COtd/WFB fff u
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 Qcv. Erich L Ibtal I
Fee for all residential systems combined: S75.00 Renewable electrical energy systems:
Check Type of Work Involved: s 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
Gara a Door O ener* 50.01 to 100kva 552.26 2
g p >100 k (fva(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
❑ 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 1
charged at an hourly(1 hr min)
Inspections for which no fee is 90 00/hr
specifically listed(Y hr min)
COMMERCIAL WORK ONLY: -' _i a ELECTRICAL PERMIT, FEES: - . .,
Fee for each commercial system: S75.00Subtotal(Enter on Page 1):
yem: * 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
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
Other: A M S IL S,S-'e..wt
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I�'I 1:\Building\Permits\ELC PermitApp_ELR_ERE.doc Rev 06/17/2015
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