Permit 7`;.'' CIT OF TIGARD
ELECTRICAL PERMIT
„.: , COMMUNITY DEVELOPMENT
0 .,_. Permit #: ELC2009-00657
T I G A R D. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 12/11/2009
Parcel: 1 S 134CD03700
Jurisdiction: Tigard
Site address: 11960 SW 121ST AVE
Subdivision: LERON HEIGHTS NO.3 Lot: 71
Project: Durrett
Project Description: Electrical reconnect.
Owner: FEES
DURRETT, BARBARA P Quantity Description Date Amount
11960 SW 121ST
TIGARD, OR 97223 1 ea Reconnect Only 12/11/2009 $67.84
PHONE: 1 ea 12% State Surcharge - 12/11/2009 $8.14
Electrical
Contractor:
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $75.98
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 accord - . _ • 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. ATTE •N: Oregon =w requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0r 0 through OAR 952-P : -r 00./ , u may obtain a copy of the rules or direct questions to OUNC by calling 503.246 .699 or 1.800.332.2
1 r
Iss ed By: - // �� 6 / / Permittee Signature: � � / A
A_ ��
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 permk 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.
it ��� to
Electrical Permit Applic , 1 , :
n I 3 ,.,. City of Tigard DEC 1 1 2.009 Received � 6 :J;' �j' e /� /}/) 5
III Date/By: / 9 . // �✓ / .. Permit No.t O*�✓ /
13125 SW Hall Blvd., Tigard, OR 97223 RD Plan Review
Date/By:
Phone: 503.639.4171 Fax: 5039 ® TIGA Other Permit:
I I ( n IL I Inspection Line: 503.639.4175 pt IILDI 1 `tG DIVISION Date Ready /By: orris: El See Page 2 for
.' <.- -•- , 'i Internet: www.tigard - or.gov L Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction ❑ Addition /alteration /replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "1 -3 ",
Job no.: Job site address: i iC ( S to 0.6t ss A Je 100 HP or more. occupancy.
❑
❑ Six or more residential units. Recreational vehicle parks.
City/State/ZIP: ` l� 2 2_2.3 ❑ Health -care facilities. ❑ Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: M ` i� � , 1�i (e-'1- ❑ Service or feeder 600 amps or more.
f" `✓ FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. 1 Fee. 1 Total 1
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'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK - (with above sq. ft.) 67.84 2
Limited energy, multi - family 67.84 2
residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
. ❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: " T . 4-. a (( 401 amps to 600 amps 200.34 2
CO � g( ) 601 amps to 1,000 amps 301.04 2
Address: I & ° s� 1 a' S`f A f e O C L r• (t - Over 1,000 amps or volts 552.26 2
City/State/ZIP: 1. t D k_ 9 Z2 3 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (5t3) 3(.'g'- c 7i ( ) 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
intended for sale, lease, rent r exc . :.e, accord' s ORS 447, 449, 670, Id 7y1 . 401 amps to 599 amps 168.54 2
Branch circuits – new, alteration, or extension, per panel
Owner signatur�.c. k Date: �ol // A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee,
each branch circuit 7.42 2
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 56.18 2
first branch circuit
Address: Each add'l 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 only 67.84 ,�'7. W 2
E -mail: Pump or irrigation circle 67.84 2
C NTRACTOR . Sign or outline lighting 67.84 2
Business name: Signal circuit(s) or limited-
— energy panel, alteration, or
Address: //7 extension. Describe: Page 2 2
City /State /71P: Each additional inspection over allowable in any of the above
Per inspection 66.25
Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 66.25
CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 78.18
ELECTRICAL PERMIT FEES •
Suprv. Electrician signature, required: Subtotal: y
Print name: Date: Plan review (25% of permit fee): • t
State surcharge (12% of permit fee): g • / L/
Authorized signature: TOTAL PERMIT FEE: —75 .9g
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.
1:\ Building\Permits\ELC- PermitApp. doc 10/01/09 440 -4615T(1I /05 /COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined .. $67.84
Check Type of Work Involved:
n Audio and Stereo Systems*
F7 B • urglar Alarm
n G • arage Door Opener*
H Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $67.84
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
n C • lock Systems
❑ Data Telecommunication Installation
❑ F ire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
n Landscap.e Irrigation Control*
❑ Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
Fl Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1:\Building\Permits\ELC- PermitApp.doc 10/01/09
Dec. 11, 2009 4:18PM PGE —PSC SERVICE CORD No, 33,5 P, 1
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QUESTl SU VISINO EL.ECTRIC1 FON I ATION '
Nona: of sitperrisinp electrician. C C. �ikL — , , ate of request: _ ::;L/ / _____
Supervising electrician's license number bate instrlladon as completed; I ! ! l ,
Elttettttai penult no.: 4(a nelnparwy prrmir ft ported ur ale Job Ilse plcarrc inc/rydc a ropy of .r Hirt, dii.r farm.
M ELECTRICAL O ACTOR 1 P - - - , -
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OUSTO' &R h1FORMAI1ON
Cava mec's name: Q�L _ 0 • _ -
Cus address: \P1
City: C Cc Stare : [ 1� Zit;
Address of 1huSOn differont than euxturner'5 address: . - .:
City _ State- I.
IN FICOTING A11TMOpI INFORgATIQN _ •
Authority having jurladlta O11 to 111apeei i� -: -; - ■ • ' r r' • Fholw) - -
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- RECEIYINe ELE 1C 1LIT1r INFQAAY9A' 7 1�I
Nu{ne of electric utility receivinS rt:Quese -_ •`t'C'" L _ Phone; - -
Address: 1
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City: S
ZIP:
RE • 4. ■ FOR REQUEST ,
A. Restoring electrical services that wail intorruprad at' dlseonnacced becauat= of either :a:
* ' change or ❑ 1.111cot ovum, such a: tire, flood- or eavero .wit
or �
R Electrical service Ala remote Iocadon ut;t:da to be:
❑ lnleialiite Restored
COMPLETION IN T o AN SIGNATURE
Supervis nc elec1i - 1 (ut Electrical C4tttraClor'
Meese pate— After sending tike farm to tha elcctnv Please note — By eIOSC Of business on the first business
Utility named above. you muse send a copy of Chit farttt lb: day following anergiiing of a completed Inenallutk in
(1) the electrical contractor. 12) tho ellrterntr, and (3) the eespaesa TI) the above rrquca , you nrusll (1) notify the
inxpeating awiherity. authority haying jurtsdit rton Mat ens laletanAtian 1wx Ito=
17~ ..� ?t . '• � C�} cample and u 2) reh�st that the annuity Inspect the
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