Permit
L Y
CITY OF TIGAR® ELECTRICAL PERMIT
$ COMMUNITY DEVELOPMENT Permit#: ELC2009-00539
4 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/08/2009
Parcel: 2S112D000500
Jurisdiction: TIGARD
Site address: 15895 SW 72ND AVE 200
Subdivision: OREGON BUSINESS PARK III Lot: 40
Project: CIDA
Project Description: Install (1) 200 amp or less service and add/alter (20) branch circuits.
Owner: FEES
PACIFIC REALTY ASSOCIATES Quantity Description Date Amount
15350 SW SEQUOIA PKWY #300
PORTLAND, OR 97224 1 ea Services or Feeders 200 10/08/2009 $100.70
amps or less
PHONE: 503-624-6300 20 crt Branch Circuits w/Purchase 10/08/2009 $148.40
Service or Feeder
1 ea 12% State Surcharge - 10/08/2009 $29.89
Contractor: Electrical
JOHANSEN ELECTRIC INC
10984 SE VALLEY VIEW TERR
HAPPY VALLEY, OR 97086
PHONE: 503-698-3417
FAX: 503-698-2486
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $278.99
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 0 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 through OA 952-001-0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800 332.2344.
Issued By: - J~z Permittee Signature:
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' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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 TigardReceived QQ
DateB Pcnriit Vo. q
13125 SW Hall Blvd., Tigard, OR 97 Plan Review l
Phone: 503.639.4171 Fax: 503.599.1 Other Permit:
Inspection Line: 503.639.4175 Date Readyiay kris See page 2 ror
Internet, www.tigard-or.gov 1~. Noufied,,Method: Supplemental Information
!
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' 'tfl#:~t+li`srt!'[ R~ W
❑ New construction Addition/alteration 1C IAbttt Please check all that apply (submit 2 sets of plans wliter,, checked below).
' ❑ Service or feeder 400 amps or more
❑ Building over three stones.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
sSy,
101 'I exceeds 10,000 amps at 150 volts or ❑ Floating buildings,
sii+~ .t' pi., - ❑
❑ 1-and 2-family dwelling Cotnrriert iaL'indutitrtal ❑ Accessory building " less to ground, or exceeds 14,000 Commercial-use ageultural
amps for all other ias"-dons. buildings.
❑ Multi-family ❑ Master builder ❑ Other: ❑Fire pump ❑ Installation of 75 KVA or
A ❑ Emergency system, larger separately derived system.
'u3 ,.ILL u1' 1 14 ',ka 'ta
❑ Addition of new motor load of [I "A°, "l-2", -3",
Job no.; Job site address 1GOHPormore. occupancy.
❑ Six or more resicicatiat units. ❑ Recreational vehicle parks.
City/StatelzlP: ❑ Healthcare facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: 2- Do Project name: G I D A r0 Seniioc or feeder 600 amps or mo-e
Cross street/directions to job site: oe,cii d.a Fee TOW
New residential single- or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea, add-) 500 sq. ft. or portion 33.92 1
Tax rnap, parcel no
S Lted energy, residential 6784 2
~Y ) a"-:":+e l!}; u u s i,~',+ f+'t+,._ with above sq. ft.
Limited energy, multi-family 67.84 2
UOrr~ VIrnWIDYErntrIt residential (with above . ft.
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 1lCL'>.170 2
4 201 tintPs to 400 amps 133.56 2
t F ~
Name: 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 3D1.04 2
Address: Over 1,000 amps or volts 552.26 2
City/5tateiZIP: Temporary services or feeders installation, alteration, and/(r
relocation
ZPh n e: ( 200 amps or less 59 3b 1
wner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits - new, alteration, or extension, er panel
Owner signature: Dale A. Fee for branch circuits with
a)a above service or feeder fee,
~~,..i~~i
each branch circuit 7.42
Business name: Johansen eetriC B. Fee for branch circuits
Contact name: 10948 SE Valley View Terrace witixwt service or feeder fee, 56 18 2
first branch circuit
Address: Happy Valley, Oregon 97 Each add'I branch circuit 7.42 2
Miscellaneous (service or feeder not included
City/State./ZIP: Each manufactured or modular
dwelling, service and/or feeder 67.84 2
Phone: ( ) Fax: ( ) Reconnect onlv 67.84 2
E-mail: Pump or irrigation circle 67.84 2
07 . ~ tv ) #i 11( t iA+ Sign or outline lighting
67.84 2
Business name: JohanSeA eC IC Signal circuit(s) or limited-
enerpv panel, alteration, or
address: 970136 extension. Describe: Page 2 2
Wmappy Valley, Oregon
City/State/ZIP: CCB # 51539 Each additional inspection (vet allowable in a(, of the above
Phone' (F O Fes: Per inspection 66.25
If!"I D L7 tr° investigation per hour(] hrmi,) 66.25
CCB Lic.: Cj~rj7S~ Electrical Lic.: Suprv. Lic.: 2 !2C Industrial plant per hour 78.18
7 i.
Suprv. Electrician signature, required: Subtotal: Z , 10
Print name:
Caa( D~ } Date: !f~ Plan review (25%ofpermit fee):
State surcharge (12% of permit fa): ! gq
Authorized signature: TOTAL PERMIT FEE: Z-1
Print name " Date: / /r Tbm l~rmit aPPlication expires if a permit is not obtained within 180
('(gyp 11 days after it has been accepted as complete.
• Number of inspections allowed per permit.
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