Permit (6) Electrical Permit Applicatio1RECEIVE
FOR OFFICE USE ONLY'
City of Tigard Received �1 _
:� 13125 SW Hall Blvd.,1 igard,OR 97223 Date/By: 1 .�a Pemrit No.: �- OeI1- )i
Phone: 503.715.2439 Fax 503.598.1960 JAN 6 2021 Ptan Review .�s��wv
ns coon Line: 503.639.4175 Date/By: Other Pennir.
TIC A R D I Date Ready/By:
TV T l�.A t-rt� i
Internet: www.ligard-or goy CITY f OF I IG RD 'Method: _ P . ' Fa S See Page 2l for
��ry�t� Noiif� � Supplemeolallnformalimn
TYPE OF wdiliA DIVISION t"
PLAN REVIEW
❑New construction 0 Addition/alteration/replacement PI chick all that apply(subnin 2 seI of plans u-liana chcckM below P.
- ❑Servicc or feeder 400 amps or mom ❑Building over three slariee.
❑Demolition 0 Other:
-- i where the available fault currem 0 Maims and boatyards
CATEGORY OF CONSTRUCTION exceeds 10.000aos sat 150 volts or s.
P ❑Floating buildings.
ElI-and 2-family dwelling ®Commercial/industrial ❑Accessorybuilding - less to ground.or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
❑Multi family ❑Master builder 0 Other 0 Fire pump
�5v)'; 5'yp^ (]Imiallauon of 75 KVA or
3, %*v ' JOB SITE, WFORMAIr1� ND LOCATION ❑Eioergeney system. larger separately derived system.
(I ❑Addition of new motor load of ❑larger
E. -1 2' 1 s Job no.: I Job site address: I I95(i Sw Garden PI 4,ct ooHP or more. occupancy.
x5Z 1 S 0 0 Six or mom residential units, 0 Recreational vehicle parks,
City/State/ZIP:Tigard OR D Heald,-care facilities. 0 Supply voltage for more titan
❑1 lazardous locations. 600 volts nominal
Suite/bldg./apt.no.:Bldg 7 Project name:BKM Building?Tl/ 0 Service or feeder Goa amps or mord.
Cross street/directions to job site: ` �� : FEE SCHED�I.E.
Description I *'
New residential single-or multifamily dwelling unit.Fee. I tan
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq.ft.or less 168.54
4
Tax map/parcel no.: Ea add'I 500 sq ft.or portion 33.92 I
DESCRIPTION OF WORK Limited energy,residential
(with above sq.ft.) 75.00 2
Relocate thermostats as required for office layouts Limited energy,multi-familyresidential(with above sq.ti.) 75.00 2
( Services or feeders installation,.alteration,and/or relocation
t�` --_. 2(10 amps or less 100.70
Cf. ❑ PROPERTY OWNER 2
C __ ❑ TENANT 201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
�'� 601 amps to 1,000 amps 301,04 0
s Address:
Over 1,000 amps or volts 552.26 2
City/State/ZiP: Temporary services or feeders installation,alteration,andlnr
relocation
Phone:( ) Fax:( ) 200 amps or less 59.36
1
Owner installation:This installation is being made on property that 1 own which is not 201 amps to 400 amps 125.08 2
13 intended for sale,lease,rent,or exchange,according to ORS 447.449,670,and 701. 401 amps l0 599 amps 68.54 2
Owner signature: Branch circuits-new,alteration,or extension, per panel
( Date: A.Fee for branch circuits with -
❑ APPLICANT I 0 CONTACT PERSON above service or feeder fee,
7.d2 2 each branch circuit
Business name:same as below'
B.Fee for branch circuits withorn
Contact name: sets ice or feeder fee,first
branch circuit 56.18 2
Address:
t
City/State/ZIP: Each add'I branch circuit 7.42 2
__ Miscellaneous(service or feeder not included)
Each manufactured or modular
k/ dwelling,service and/or feeder 67.84 2
Phone:( ) Fax: :( ) Reconnect only
F-mail 67.84 2
'('x(�r-a1 1,a1`14 Pump or irrigation circle 67.84 2
CONTRACTOR wn 'Iva( t
[� �. Sign or outline lighting 67.84 2
a t. t"`_ . Signal circuits)or limited-energy t
,�.. Business name: Willamette HVAC LLC -
panel,alteration,or extension. 1 Page 2 7,5; 2
Address:3075 SE Century Bls d Suite 206 Each additional inspection over allowable in anv of the above
Additional inspection(I hr min) 66.25/hr
City/State%ZIP:Hillsboro,OR 97123 �/r/Z� Investigation 11 hr min) 66.25rht
Phone:(503)259.3200 - ' F• . �}",-/t Industrial plant(1 hr min) 78.18/hr
3 i tls Fax:(503)g4g.2597 Inspections for which no fee is '
""���/S r specifically listed(b_hr min) 90.00!hr
CCB Lie.: 56951 Electrical Lie.: 24116CAG Suprv. Lie.: 4025LEB
/� ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: _ (/ —
Subtotal 7 j
`� _` Dc-C�CJr,:.Y Plan review(25%of permit fee):
Print name: mike sicard I Date: 1/4/2021 State surcharge(12%of permit fee): -1 'f�
�f
Authorized signature: ;y,p'MLA., TOTAL PERMIT FEE: ty (,
This permit application expires if a permit is not obtained within 180
Print name: Michael Malstrom Date: 1/4/2021 data after it has been accepted as complete.
' Number of inspections allowed per permit.
I:£landlnv Peoni,,ft('Pe mnApp.doe 07 01:10
440-0(i I STtl I COM wEn