Permit Electrical Permit Application I of OFFICE USE ONI.l'
Received
City Of Tigard Date/B : . .jot- (IT,, ;'emit a: - ),6 - t'-C�y'l
• 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.196 pare ; Related Permit#:
Inspection Line: 503.639.4175 N OI S I' (j JfnNI of I(I Ready Date/By: la See Page 2 for
TIGARD Internet www.tigard-or.gov (.7HHVOLI 30 I AU" Notified/Method: Supplemental Information
TYPE OF- 'o 4_, : r.; )Fw
❑New construction 0 Addition/alterati
•on/rep acement Please check all that apply(submit 2 sets of plans w/hems checked):
. 0 Service or feeder 400 amps or more 0 Building over throe stories.
D Demolition El Other: ::_,_,�,,,»t 4- where the available fault current ❑Marinas and boatyards
CATEGORY OF CONSTRUCTIOIVv • ' - x. ' exceeds 10,000 amps at 150 volts or ❑Floating buildings.
❑ 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less so ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family 0 Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
1 JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
0 Addition of new motor load of system
Job#: I—Job site address: /1j o.jo bt / avoj-x , r e,"/ I00HPormore. ❑"A "E" "I-2" "i-s»
City/State/ZIP: rk D L}`j 2 Z 3 ❑Six or more residential units occupancy.
❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: I Project name: \1 .L1 1 ❑Hazardous locations. 0 Supply voltage for more than
✓✓✓ 0 Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SGHEDUL
Desaipnon QM Lash Telat •
New residential single-or multi-family dwelling unit.
Subdivision: I Lot 4: 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
(1) /^ ,1 J a, (with above sq.ft.) 75.00 2
OafN44 G r i�Gvt i / RJl /t s y vvf , Limited energy,multi-family
v r residential(with above sq.it) 75.00 2
Renewable Energy ❑ See Page 2
9 tin *^`rear'' :.. D4 t UW" Services or feeders installation,alteration,and/or relocation
Name: C A JAI
1 11.) 200 amps or less 100.70 2
Address: 1 01 C'I 6- cvk ple.P 1_ 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP: j f e et r ek 6 IL 1 i ' - ' 601 amps to 1,000 amps 301.04 2
-p(jpEe:(Vs') 3 f3 t.4 b-0 2 V Fax:( ) - Over 1,000 amps or volts -552.26 2
l t Temporary services or feeders installation,alteration,and/or
Email: r� 1 i c.� ,,GL I. ..,...a...-„.. relocation
Owner installation:This installatidn is eingmmade on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease, t,or h.pge4 .ording to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: ‘ .. Date: (( '2"
2_ 401 amps to 599 amps I 168.54 2
0 APPL CANT 0 CONTACT PERSON Branch circuits—new,alhratio�or extension,per panel
A.Fee for branch circuits with
Business name: icayx.2 J II,-. f� above service or feeder fee, 7.42 2
6 each branch circuit
Contact name: B.Fee for branch circuits without
service or feeder fee,first I 56.18 2
Address: branch circuit
City/State/ZIP: Each add'I branch circuit I 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) I Fax: :( ) Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Lmail: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: 0.(h-,f5' Sign or outline lighting 67.84 2
Signal circuits)or limited-elegy ❑ See Page 2 2
Address: panel,alteration,or extension.
City/State/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) I Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(I hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lie.: I Electrical Lie.: I Suprv.Lic.: specifically listed('7:hr min)
ELEGTRICit YER11tiT FEES
Suprv.Electrician signature,required: Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE: Ci, I),
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',1Building\PermitstELC_PermtApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(11/05/COMAVEB
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
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 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
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.
Om)
�
Print Name 6f Permit Applicant
crz
Signat a of Permi plicant Date
Permit#:
II
Address: ) I Li C
AAl I 1
1.�
Issued by: Date:
This Copy for Permit Offices