Permit 11P
FOR OFFICE USE ONLY—SITE ADDRESS:
This form is recognized by most building departments in the Tri-County area for transmitting information.
Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
i
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
' _ " Transmittal Letter
r i cc A R t) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: 11 NA CSccj e,„(,, DATE RECEIVED:
DEPT: BUILDING DIVISION C I V C
FROM: Get wln y Sc_ it urviciA/ MAR 1 n 2022
COMPANY: ul 1 Y UI- IIGAHIJ
PHONE: q- [ - 29 C - I L-1 Z '3- MIMING DIVISIO\BY:
EMAIL: q a i y &_L1 W1 Snf Corot
RE: f `f I i c CO PoX 1.k)e)ej Cl—
(Site Address) (Permit Number)
LtiPeiqt0774.1/?l4 1 ( I Lc.)-'f- (el
(Pwjectfiame or subdivision name and lot number)
ATTACHED ARE THE FOLLOWING ITEMS:
Copies: I Description: Copies: Description:
Additional set(s)of plans. Revisions:
Cross section(s)and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
/ Beam calculations. ( Engineer's calculations.
V Other(explain): Coh r Pr--rC�cl L L c -t n i Cc, ! Pc' I,n. i-r A Fyp
REMARKS: 4 S' utied 0 vi-i-y ac..ow 2 S-fi.1'-t--rvi eta?
-Is'In3a t C, t c94) - 'Ci /4 New+ c--�-1- 12 �v -�() if-- h-/n,•L
Tk c Al.- C C C . T L ( t`b (.0 14 Le 0 P �2 k) �p ?�
-tilAw� c , y
FOR OFFICE USE ONLY
Routed to Permit Technician: Date: Initials:
Fees Due: ❑ Yes ❑ No Fee Description: Amount Due:
$
$ i
$
Special
Instructions: I
Reprint Permit(per PE): ❑Yes ❑No Done
Applicant Notified: Date: Initials:
`.7
Electrical Permit Application E C E I V E C 1 4//It I II I It : I 1 1 i
115. City of Tigard Received 3 t Ito ZZ \ J it"'"`": _ (ZO - CIO VI
13175 SW Hall RNA Tigard.T oeard,OR 97223 MAR 1 0 202� Pun.Review
9 Phone: 503.718.2439 Fax: 503.598.1960 I Date1By: I Related Permit o: I
inspection line: 503.639.4175 I I Iv' If�1�7HI�L Ready oateiBy: �1�,2..Z B See Page 2 for
f l t I N it 1, Internet www.tigard-or,gQv IIJ ILDING DIVISIOfr Notified/Method: S.pptesse.ml Information
TYPE OF WORK I P!Art REVIEW
a-�i PLwae eh,—.CI,.111 NYat w(a_i,e r=K9 of plum,.v/items •c1Y*'kM):
❑New construction w Addition/alteration/replacement
0
Service or feeder 400 amps or morc 0 Building over three stories.
❑Demolition ❑Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
IE 1-and 2-family dwelling 0 Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commcre"lal-use agricultural
amps for all other inertallations. buildings.
• ❑Mnitl-[drolly 0 Master builder ❑OtheT: I 0Fire pump. 0 installation or 150 ii"vA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
❑Addition of new motor load of system
Job#: Job site address:1 l l 75 Sul 1304 .4 ca L GT' I00HP or more. ❑"A","E". l-r'."I-3
� �J ❑Six or more residential units. oaupancY.
City/State/Z1P: -1--;go,,d,Q'` q 1 z 23 ❑Health-care facilities. 0 Recreational vehicle parks.
V 0 Supply volts for more than
I Suite/bldg./apt#: Project name: tikge f�rvLot1Gtc ON ❑ ror feederService 600 amps or more.
Cross street/directions to job site: o F F .5(..j col..4e4 L.ociend FEE SCHEDULE
nuerlWta. I Qty. I FAA I TWt I '
New residential single-or multi-family dwelling unit.
ISubdivision: ' t I Loot: 1 e f taciude-a at:shed garage.
L N l e L1, [ L I V / ( 1 1,000 sq.itor less f i 168.54 i i 4 I
Tax map/parcel#: Ea add'l 500 sq.ft.or portion 33.92 I
DESCRIPTION OF WORK Limited energy,residential 75.00 2
p (with above sq.ft.)
r Rna II, 9L sa,a�' L.c l.r-rS lSi,r-r C thl (r,CNo!/s- . ` Umi.ted-_.�rt,y w fend.
r t t J f---! I I w.^u. -. ...., 1 75.00 2
( f� resldeon•st(with be an,.ft_)
Pr4Ct LrS i-f-r rL & L r!t rJ('t-rS T o 6,404,1e F'T Renewable Energy . - ❑ see Page Z
NI PROPERTY OWNER I 0 TENANT Services or feedersinstallation,alteration,and/or relocation
Name: GA N t.y S G. K t14)14) C-Cct,-In 1C (3e,_( _k'� 200 amps or less l 100.70 2
Address: W6Q 40 Gi/•" 1 1 401 amps W 600 amp 201 amps to dM amps
l l (-7 5 ScJ C( I I 10034 33.56 I 1 2 1
City/State/ZIP: -N-fj G t,t jam/ U' z C?3- 2 2 3 601 snips to 1,000 amps 301.04 12
Phone:(9 ri ) 2 (3 5 ( ` 2 '4, Fax:( ) Over 1,000 snips or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email' 10t r T Jc—Lvt r-,-5.-.,, .'• e • /c.—.mo'w.
relocstlsn
Owner Inlfallation:This installation is being made on property that I own which is not 200 amps or less I I 59.36 I t I
intended for sale,lens4�,rf�rlt,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature:/ J .A •---- Date: 31(0 /2_,
401 amps to 599 amps 168.54 2
1-1 it opt nr•sny / I f_I CONTACT PERSON circuits-new,alteration,or extension,per panel
T
I I I A.Fee fa'branch chalets with I I j
Business name: above service or feeder fee, g 7.42 2
each branch circuit
Contact name: H.Fee for branch circuits without
Address: - service or feeder fee,first 56.18 2
branch circuit
City/State/ZIP: I i Each add'l branch circuit I I 7.42 I 12
Miscellaneous(service or feeder not included)
Phone:( ) Fax::( ) Each manufactured or modular
dwelling,service and/or feeder 67.64 2
Email: Reconnect only 67.84 2
CONTRACTOR I I Pump or irrigation circle I 6714 12
Business name: Sign or outline lighting 67.84 2
Address: Signal circuit(s)or limited-energy ❑ See Page 2 2
panel,alteration,or extension.
Each additional Inspection over allowable hi any of the above
City/State/7.1F: , ,
I I I Additional inspection(I air nun) I 66.25/lit
Phone:( ) I Fax:( ) investigation(l hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90 00/hr
CCB Lie.: I Electrical Lie.: Suprv.Lic.: specifically listed ph hr min)
I ELECTRICAL PERMIT FEES I
Suprv.Electrician signature,required; Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):Di
signature: f�a-Al 'Sc TOTAL PERMIT FFF_
Authorized si re: i 1 i
` This tisi'udt appaeadou expires if a permit Is nut ubtalaed geltala 180
' Print name: t�d,y,y �jc-I t 64✓VI A ti Date:3 r(0 J Z Z days after It leas been accepted as complete.
l ' Number of inspections allowed per permit.
I:\Building\Pennits1ELC_PemhitApp-ELR FRE.doc Rev 06/I 72015 440-4615T(II/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
Fee for all residential systems combined: $75.00 Renewable Qty. Each Total )
y electrical energy systems:
Check Type of Work Involved: s kva or less ( I 100.70 I 12
5.01 to 15 Asa 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 12
❑
Burglar Alarm Wind generation systems in excess of 25 kva:g 25.01 to 50 kva 301.04 I 12
50.01 to 100 kva 552.26 2
❑ Garage 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 7A2 3
❑ Vacuum Systems* >100 ha-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(l hr min)
inspections for which no lee in
lir
specifically listed(%,hr min) I 90'00/
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system: $75.00 Subtotal(Enter on Page 1):
(SEE OAR 418-309-0000) * Number of inspections allowed per permit.
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
El Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ H VAC
❑ Instrumentation
El Intercom and Paging Systems
❑ Landscape Irrigation Control*
El 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
t:ufuildinguPenorts\LC_PerntirApp_GLK EKE.doc Rev nrrl%ILul>
Information Notice to Owners About
.,*itii Responsibilities
Construction
(ORS 701.325 (3))
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
4FCE
Property Owner Statement IVEr;
Regarding Construction Responsibilities MAR 10 2022
Oregon Law requires residential construction permit applicants who are not licensed with tire' Y OF I I(LAHL
Construction Contractors Board to sign the following statement before a building permit cdn'bldlNG DIVISJ v
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
gI 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.
&7 v, y � � LA evict,
Print Name ofPermitApplicant
.4e/il/t/tAl
// /2-2--
Signature of Permit Applicant Date
I I
Permit#:
Address:
z
Issued by: _ Date:
This Copy for Permit Ottices
CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2022-00173
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 4/11/2022
Parcel: 1 S134ACO2624
Jurisdiction: Tigard
Site address: 11175 SW BOXWOOD CT
Project: Baker Subdivision: ENGLEWOOD NO.3 Lot: 181
Project Description: Add additional lights to garage,replace lights/outlets in garage
Contractor: OWNER Owner:
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 sf Permit Fee-Elect(SF or 1 st 03/17/2022 $168.54
Specifics: MF dwelling unit)
1 ea Services or Feeders-200 03/17/2022 $100.70
Type of Use: SF amps or less
Class of Work: ALT 8 crt Branch Circuits w/Purchase 03/17/2022 $59.36
Type of Const: Service or Feeder
Occupancy Grp: 1 ea 12%State Surcharge- 03/17/2022 $39.43
Electrical
Total $368.03
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, Stale 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 coov of the rules or direct questions to OUNC by calling 503.232_1987 or 800.332.2344.
Issued By: /tom '/! � Permittee Signature: 61f1 7111A&.GL�lv
OWNER INSTALLATION ONLY
The installation is being made an 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.