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Permit (7) CITY OF TIGARD ELECTRICAL PERMIT • COMMUNITY DEVELOPMENT Permit#: ELC2022-00562 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 8/22/2022Parcel: 2S104AD02100 Jurisdiction: Tigard Site address: 12585 SW 128TH AVE Project: Tesler Subdivision: BELLWOOD Lot: 48 Project Description: Replacing 200 amp service. Contractor: OWNER Owner: TESLER, LARRY LO,APRIL 12585 SW 128TH AVE PORTLAND, OR 97223 PHONE: PHONE: FAX: FEES Quantity Description Date Amount 1 ea Services or Feeders-200 08/22/2022 $100.70 Specifics: amps or less 1 ea 12%State Surcharge- 08/22/2022 $12.08 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $112.78 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 reciuir ou to folio the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through O 9 -001- � Y a obtai v o e rules or direct auestions to OUNC by calling 503.2 . 87 or 1.800.332.234 Issued By: ermittee Signature: D— 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 FIECEIVED Received U 13125 SW Hall Blvd.,Tigard,OR 97223 Date/By: . g Plan Review Phone: 503.718.2439 AUG 2 2 2022 Date/By: Related Permit#: Email: TigardBuildingPermits@Tigard-or.gov y Ready Date/By: Jurh: ® See Page 2 for Inspection Line: 503.639.4175 Intern � vga� � Notified/Method: Supplemental Information :. E OF,w 1 .AN R vv ❑New construction ®Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked): ❑Service or feeder 400 amps ormore ❑Building over three stories. ❑Demolition El Other: where the available fault current ❑Marinas and boatyards. CATEGORY OF CONS)(ROCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings. ® 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural Multi-family Master builder Other: amps for all other installations. buildings. ❑ y ❑ ❑ ❑Fire pump. ❑Installation of 150 KVA or ; $b] E bj'A1�Tb LOCA1)ION ❑Emergency system. larger separately derived ❑Addition of new motor load of system. Job#: Job site address: W 2ILA 100HP or more. ❑"A""E","1-2" "1-3" City/State/ZIP: 7 u ❑Six or more residential units. occupancy. ❑Health-care facilities. ❑Recreational vehicle parks. Suite/bldg./apt.#: Project name: ❑Hazardous locations. [3 Supply voltage for more than ❑Service or feeder 600 amps or more. 600 volts nominal. Cross street/directions to job site: SW WCAVIA SL FE);S03iJI.E Description I Qty. I Each I Total 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'1500 sq.ft.or portion 33.92 1 mSCItI 4IrI� Limited energy,residential 75.00 2 ` - with above .ft. .ham r V t Q Q e Limited energy,multi-family residential with above sq.ft.) 75.00 2 Renewable Ener [3 See Page 2 'fly J TOO* Services or feeders installation alteration and/or relocation Name: Larr Tes I r 200 amps or less 100.70 2 Address: I I.S95 S 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 City/State/ZIP: k;46 ,f- / 7 f-2 601 amps to 1,000 amps 301.04 2 Phone:(396 ) 7 *5 ^ 2 a 3 01 Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or Email: -a �, �rY- (Y1O�1 �' relocation Owner installation:This instal ation 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 X7101. 201 amps to 400 amps 125.08 2 Owner signature: Date: 401 amps to 599 amps 168.54 2 Branch circuits—new,alteration or extension, er panel "= - APLICl�NI ❑ CON"1'z�CT P1� Sorl ' A.Fee for branch circuits with Business name: above service or feeder fee, 7.42 2 each branch circuit Contact name: L&,&r4 (` B.Fee for branch circuits without service or feeder fee,first 56.18 2 Address:JIS S W h branch circuit City/State/ZIP: 2 Each add'1 branch circuit 7.42 2 Miscellaneous service or feeder not included Phone:&(Q ) `7 _;Z� Each manufactured or modular 67.84 2 /'� dwellin service and/or feeder Email: este 1" I /��t 1, Reconnect only 67.84 2 COR14C1°©R,. Pump or irrigation circle 67.84 2 Business name: Sign or outline lighting 67.84 2 Signal panel,alteration,oor extension. ❑ See Page 2 2 City/State/ZIP: Each additional inspection over allowable in an of the above Additional inspection(1 hr min) 66.25/hr Phone:( ) Investigation(1 hr min) 90.00/hr Email: Industrial plant(1 hr min) 78.18/hr Inspections for which no fee is 90.00/hr CCB Lic.: Electrical Lic.: Suprv.Lic.: specifically listed '/z hr min ELECTRICAL`PERMIT FEES Suprv.Electrician signature,required: Subtotal: 100.70 Print name: Date: ❑Plan Review Required(25%of permit fee): State surcharge(12%of permit fee): Authorized signature: TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 Print name: Date: days after it has been accepted as complete. * Number of inspections allowed per permit. I:\Building\P=its\ELC_PcrmitApp_ELR_ERE.doc Rev 10/26/2017 4404615T(11/05/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: PXSIDENTAL°�'4It 'Ol�iI,Y .. �� Desai tion Each I Total 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 F-1 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 ❑ Vacuum Systems* >I 00 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 hourl 1 hr min Inspections for which no fee is 90.00/hr s ificall listed %hr min -- M. Subtotal(Enter on Page 1). 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 ❑ Instrumentation ❑ Intercom and Paging Systems ❑ 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 1ABui1ding\Permits\ELC_PermitApp_ELR_ERE.doc Rev 10/26/2017 Property Owner Statement EEIV'E p Y Regarding Construction Responsibilities AUG 2 2 2021 Oregon Law requires residential construction permit applicants who are not licens �,NHo� Construction Contractors Board to sign the following statement before a building p VISION 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 1 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. Print Name of ermit Applicant Ca2 Signature of—Permit Acant Date Permit#: Address: Issued by: Date: This Copy for Permit Offices Information Notice to Owners About Construction Responsibilities (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, call 503-945-8091 or go to httl2://www.orecion.gov/DOR/BUS/docs/211-055.12df for the appropriate forms. • 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 503-947-7815. • 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, call the IRS at 1-800-829-4933 or visit their website at www.irs.aov. 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.oreaon. oq v/ccb f/property owner adopted 9-23-08 This Copy for Permit Applicant