Permit (26) Electrical Permit Application FOR OFFICE USE ONLY
City5 of Tigard RecDECEIVED ived
Date/By: 7g11.3 �� tNe.: ,�3��, __''�`ll 433
13125 SW Hall Blvd,Tigard,OR 97 W
Plan Reviewifiir:,4 seer permit: ,r 1„�? �Lrd5.7
Phone: 503.718.2439 Fax: 503.598. Date/13y: % i7T7lfJJ l GW
T 1 G n R D Inspection Line: 503.639.4175 Date Ready/By: hods: ® See Page 2 for
Internet: www.tigard-or.gov JUL 2 4 2023 Notified/Method: In" � Supplemental Information
TYPE OF WORK OF TIGARD 6�/ 'e' +/ PLAN REVIEW
❑New construction ®Addition/alterati 1l p t,i Please k all that apply(submit 2 sets of plans w/items checked below):
U�VIJIQi� ❑Service or feeder 400 amps or more
❑Demolition 0 Other: p 0 Marinas over o three d.stories.
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
less to ground,or exceeds 14,000 0 Commercial-use agricultural
❑ I-and 2-family dwelling ®Commercial/industrial ❑Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system.
0 Addition of new motor load of 0"A","B","1-2","1-3",
Job no.:887 I Job site address:9370 SW GREENBURG ROAD, • 100HP or more. occupancy.
0 Six or more residential units, 0 Recreational vehicle parks.
City/State/ZIP:TIGARD,OR 97233 I$Heelth-cane facilities. 0 Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.:STE 204 Project name:WASHINGTON SQUARE ENDOfl 4 Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site:SE CORNER OF HALL AND GREENBURG Description I Qty. I Fee. I Total I
•
Z� ��� � O� � New residential single-or multi-family dwelling unit.
j,)y ,,j 4,,.... -t C�II /74 Includes attached garage.
Subdivision: '� L I Lot no.: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
Tax map/parcel no.: Limited energy,residential
75.00 2
DESCRIPTION OF WORK (with above sq.ft.)
Limited energy,multi-family 75 00 2
NEW SELECT BRANCH AND LIGHTING residential(with above sq.ft)
Renewable Energy 0 See Page 2
Services or feeders installation,alteration,and/or relocation
❑ PROPERTY OWNER I ® TENANT 200 amps or less 100.70 2
201 amps to 400 amps 133.56 2
Name:DR.KENNETH WILTBANK 401 amps to 600 amps 200.34 2
Address:9370 SW GREEN BURG ROAD,STE 204 601 amps to 1,000 amps 301.04 2
//s Over 1,00(1 amps or volts 552.26 2
/.""s City/State/ZIP:TIGARD,OR 97233 Phone:(503)246-4499 I Fax:( ) Temporary services or feeders installation,alteration,and/or
relocation
200 amps or less 59.36 I
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
k, intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168.54 2
'1�Owner signature: Date: Branch circuits—new,alteration,or extension, ' r panel
® APPLICANT I 0 CONTACT PERSON A.Fee for branch circuits with
above service or feeder fee, 7.42 2
rBusiness name:TIMBERLINE ELECTRICAL CONTRACTORS each branch circuit
D.Fee for branch circuits without Business
Contact name:CRAIG GOSSETT service or feeder lee,first 1 56.18 ,/tv� ' 2
branch circuit
S Address:9414 SW BARBUR BLVD Eachadd'I branch circuit 2 7.42 1l4/ 4l 2
City/State/ZIP:PORTLAND,OR 97219 Miscellaneous(service or feeder not included)
Park manufactured or modular 6784 2
Phone:(503)313-0331 I Fax: :( ) dwelling,service and/or feeder
Reconnect only 67.84 2
E-mail:craig(a?timberlineelectric.com
`� Pump or irrigation circle 67.W1 2
.3 CONTRACTOR Sign or outline lighting 67.84 2
Business name:TIMBERLINE ELECTRICAL CONTRACTORS Signal einmit(s)orlimitcd-cmcagy Six:
panel,alteration,or extension. Page 2 2
Address:9414 SW BARBUR BLVD Each additional inspection over allowable in any of the ahoye
City/State/ZIP:PORTLAND,OR 97219 Additional inspection(1hr min) 66.25/]r
Investigation(I lirmin) 66.25/hr
Phone:(503)459-4089 I Fax:( ) Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is CCB Lie.: 160037 I Electrical Lic.: 26-121 IC I Suprv.Lie.: 4518S specifically' hr min)
ELECTRICAL PERMIT FEE
Suprv. Electrician signature,required: Subtotal: ?J-Ua.
Print name: CRAIG T Date: 07 24.23 Plan review(25u/a of permit Fee) 7,76
State surcharge(12%of permit fee): g.5--)_
Authorized signature: (�, TOTAI.PERMIT FEE: "1 D
This permit application expires if a permit is not t load within 180
Print name: Date: days after it has been accepted as complete
Number of inspections allowed per permit.
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