Permit CITY OF TIGARD ELECTRICAL PERMIT
"II $ COMMUNITY DEVELOPMENT ELECTRICAL
ELC2022-00096
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 2/22/2022
Parcel: 2S111 CD00600
Jurisdiction: Tigard
Site address: 15905 SW 98TH AVE
Project: Dickenson Subdivision: ALDERBROOK FARM Lot: 21
Project Description: Branch circuit for ductless mini split
Contractor: OWNER Owner: DICKENSON, JON
KARRAKER, SARA NICOLE
15905 SW 98TH AVE
TIGARD, OR 97224
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 02/09/2022 $56.18
Specifics:
Service or Feeder
1 ea 12%State Surcharge- 02/09/2022 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 may obtain a coos of the rules or direct auestions to OUNC by callina 503.232.1987 or 1.800.332.2344.
Issued By: Edgar-do-Maloto��c'4o Permittee Signature: $•"'
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale.lease or rent.
OWNER'S SIGNATURE: Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC'N Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
cEIVE
Electrical Permit :kpplieatio I 01(I111 It i 1 •I (isl t
City of Tigard FEB 3 2022 "Lii1;,d z cgk,zz f trf• C.Za z—000%0
e 13125 SW Hall$lsd.Tigard,OR Q7223 Mae Rau.
I Phone 503 7182439 las 503 54tikje 0f'(IGHRL) flat At Raised Primo a
Inspection Line 503 6394175 Reads C)s*ts. la Ste Page I for
11(.ARII Internet »wv.tigad-or gin 3UILDING DIVISION N.+I,Fid At*il { '" ' Sappte.eatal lafannawa
-mit OF WORK PLAN REVIEW
r Ems.'check all that his I ii renn j ten et plot..reins checked)
❑'yetis construction �1dd11n ri Alia•ration rrplJo.nm-.t 0 Oaikl ni over Am aunts
I)ran•!+[.', t)thcr ❑Seem*a feeder 4t0 amp+or an,nMamma and
❑ .1*m the available fault evolver 0 billeslde
CATI?GORi' OE CONSTRUCTION CIION covens to Urn i unps al 110 volts,c 0 f krsraj Wilda",
c
less to round or*weeds 14 OM ❑c.ornmerrral rs yntuiara1
and'_•taits t h clini( ❑(ommcroalindustrial ❑ 71ccCvuln building antra fat all orbnrb?NRenNn bvodayp
❑41uitt•lrmf!v ❑Master builder ❑tither ❑l uepanp 0 Inst,itahard150KVAOr
JOB SITE INFORMATION AND LOCATION ❑Fmeisacyapnea) havenespaauled'n'"'d
❑Addition of n en motor brad or loom
loh a 1 )rrh rite adilrcsti -J',-Et".
ISM) Sw` 1dT)+ AuE iWNPamve ❑'A",ar,-1
C ITI State xIP (� [� Q ,r ❑So a m.ae residential unov �rxiKeaty
1.I GAR l% C -17I7„T ❑ReCTEMIIMal1tM'IC puts
❑fiaalrbKpe facilities j ❑liacud.nu In.mwxs 0 SBTis,thane to mice than
Suife'Tidg apt d; I Project name [�L'i J�.j f 0 a�uc.n tredr M1)runes or mart. t+l,ohommcnaf
Crows street/directions to job site ✓y5l aS r'- ? Oi1!`,44ii Rr FEE SCHEDIULI
D.wnelw. 1 Qe. i 1.11 f Taal i •
New residential single-or multi-Tamil)dwelling unit.
Sub.l1s r•n,n'. /1 L nEARRoo vAc./l I of p 7 1 Includes'flatbed garage. -
c 1 I,IX:U sy I or ks Ib9 54 J
las.map pane I SI11.CD066�' 1
la add'i Sire sy f1 or portion 33 42
DBSC UFTTON OF WORk I smiles.)cnerg residential
l''ices•. b.
rUr �t.I.i�) tit t Sill f he. is-ill (moth abuse sq ftt
__ ___s,.. I nurelcrrg multr•famds 7500
mrckntral iwnh those tq et 1 _
Renewable F nerg_s ❑ See Page 2
Sillr—ROPERTV 0W\ER1 ❑ TEN►1'i Services or feeders installation,alteration.aadlnr relocation
Name •30iJ DICKE,ysoiJ 200 amps orless 10071)
j S i 17 S $1re/ 41 g l i nv rr C amps toam 201 amps to tail ps 133 56
Billie<s W
irtl am 600 amps 200 13
Ctr S afc ZIgP t"IGaRD OR 972Z¢ 60I amp to 1011 urnp 301(.j
Phone (608) 31 2_-9 U 6s Fax ( ) User I,IN'amps m volts 152 26
temporary services or feeder,installation.alteration.and'or
Entail ilvnJtt.k , ,1,&inks,f.eool relocation
Owner installation:This in ila:ion is being made on proper}that I own which is not 200 amps or less 5936 I
intended lot sale.(ease,rent.or eschangc,according to ORS 447,449,670,and 701 2G1 amps to 40,;amps 1251Ni 2
1.„/'� Date 211 i 20�Z and amp,In 5'fil amps 168 Sa
i)ancr.iE>nature r -. _---
j`
0 APPLICA.'T I 0 CONTACT PERSON Branch circuits-new,alteration,or extension.per panel
A Fee for branch circuits nub
Business name alone service or feeder lee 7 32
�.._...�.____...___.� each branch circuit
Contact name B Fee for branch circuits nohow
Address ace ice or feeder tee first 1 56 18 She IX 2
branch circuit
I Each add'I branch circuit -d2
Cit)Stat71P. 2
%Iiseelianeous(service or feeder not included)
r Phone I I i I as I I Each manufactured or modular 67 aJ 2
__.. .__.__-__. duelling.service&lidos feeder
1-maul Jon di cKer o q'w %rt- 'a1, , (or(, RcconneInnf} 6764
CONTRACTOR 2
Pump or irrigation cir:is 67 RJ
Business litre �j�..n,r i^ Sign or outline hrhung 67 Rt '
V _..--_--- --- Signal occultist or limit d-cncr is
Address' panel,alteration,or co.—risk., 0 See Page 2
Loeb additional inspection twee allowable in an,of the above
City-State,.ZIP' _.... -_ Adda oust umprcn,m t 1 hr mini 66 25.hr
Phew:( I I as.I 1 tnsesrigenou l l hr mini 90 chi hr
Industrial plant(1 hr mint 71 It hr
Email: '
Inspection,for which no lee is
CCD I,lc Electrical Etc- Suprs I tc if nil,wits fisted Its hr mini vn C hr
ELECTRICAL PERMIT FEES
Suprs I lcstncian signature.required
Subtotal SO I
Uate 0 Man Res rcu Required f_'s'.r•l Komi feel
_Print name Sate surcharge 112".oil permitpermitfeel ti.7s
Authorized signature: t()1 Al PI RA II Ft f VZ
') i The permit applrcaaoe*spires ita permit s eat else steed a tMa lap
Print name AIc.k to a Date' 21 r7 L^`1, L Z. •
dart atter n has bean ncrepted as complete
• Number of in Tenons af6.rred pc prance
1 amidW'Mrleu r i-LC►e'oa+ao.u.a,Ci4 au psi cis 17.:4i 1 i esu.Mi,TI 11 61401,4-Kan
•11f1M -. 1`
.. ...... .. , .'If --. I — - `ir ii 1rrif
RECEIVED
Property Owner Statement FEB 3 2022
Regarding Construction Responsibilities LATY OF ro(ARL
Oregon Law requires residential construction permit applicants who are not licensed with the BUILDING DIVISION
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 flied with the permit.
Please check the appropnate box
I own reside in. or will reside in the completed structure and my general contractor is:
Name CCl3# Expiration Date
L. i 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.
Pnnt Name of Permit Applicant
47) L--- ---72-----------'
2..i_g l 2.0 1_2_
Slta, ure of Permit Applicant Date
Permit tt _. •1'1111W•!!
Address 4, =_ ,... ':.
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7.
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Issued by ____ Date: _ ._._.__�_
This Copy for Permit Omces