Permit S4
Community Development
Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www. tigard- or.gov
FROM: ❑ Owner ❑ Applicant n Contractor t2f City Staff
(check one)
REFUND OR Name: .
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): D
CANCEL PERMIT APPLICATION. /kg)
❑ REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Q � ^ Q
Permit #: E1C�ZO(�,CK(o�{ a �� N zoo" oo Oc1`�7 , ���VZOC ( •CYJ22
Site Address or Parcel #: k r A 7 2? i s f t. C l hA) g
Project Name: t l_A ri\-01.0L keN r %- `\
Subdivision Name: Lot #:
EXPLANATION: Q_ LI\ \ Vj pQ r
op \.e°LcA
Signature: 4 CWIAQ kg A4 Date: \ • Q 4
Print Name: L Of o4 �
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
M .. r 0 ,r`.; .rss ,: ..'" E USE ONLY' k`r F< x r:
Rte to S s Admin: Date B Rte to Bld• Admin: Date / 470 B 4iFi:411111
Refund Processed: Date 1/1111.1re Invoice Processed: Date B
Permit Canceled: Date B ATM 'arcel Ta_• Added: Date B
Recei t # Date Method Amount $
1: \Building \Forms \RegPermitAcrion.doc Rev 07/26/07
$ C av Z -D - DO 2 2 ±- o0) •
¢
Electrical Permit Application , �_ / _ �' FO Rio FF I C FuUSF ONI Y r >f� ii i
o r 1,--- . t ld.' it _. f p : � 1. K.
: � City of Tigard ; f Y iReceived Permit No.: e ( , c 'W 6 �
F;�3 Date /By: •
C ° 13125 SW Hall Blvd., Tigard, OR 97223 r� O P Ian Review
, g, Phone: 503.639.4171 Fax: 503.598.1960 Q Li 2009 Date /By:• Other Permit:
'` 't Inspection Line: 503.639.4175 Date Read /B J ® See Pa e 2 for
tfriG \K:I`t P I� Ready /By: I ( L7 g
s.'tt: Internet: www.tigard- or.gov C I I ' f y= I ^Notified/Method: Supplemental Information
TYPE OF WORK 1 ' °li '' °:IN 2>lf'JEER a O ' ' PLAN REVIEW
❑ New construction 4 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 ", "l- 2 ", "1 -3 ",
❑ Six
Job no.: Job site address: / 3 '7 Z 1 ,5 / / T7 G Gt� y/ l( more. occupancy.
/ n Six o or r moo re residential units. ❑ Recreational ns{ vehicle parks.
' % G,� f!/� op-- q 'f Z. Zi 7 ❑ Health -care facilities. ❑ Supply voltage for more than
t J ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: / e / ) Project name: ,giAll A t v 1't-/ t k An r i di ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I 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
Tax map /parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 I
Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 67.84 2
r/2, /VII.) 114/ 4Ih vN e J r,iv SlP� • Limited residential (with multi-family 67.84 2
Q( b residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
I 200 amps or less 100.70 2
El PROPERTY OWNER - ❑ TENANT ' 201 amps to 400 amps 133.56 2
Name: 6.W 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: >' ap 5 - 77-1 /} C✓ 2�O Over 1,000 amps or volts 552.26 2
City/State/ZIP: PQ.4,1.4 4 Q 97.0( Temporary services or feeders installation, alteration, and/or
relocation
Phone: (co5 ) l-1 Z — /Too Fax: (s73) Zzl 3 200 amps or less 59.36 1
Owner 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, per panel
Owner signature: Date: A. Fee for branch circuits with
/ Et APPLICANT . I . ❑ CONTACT PERSON above service or feeder fee,
f each branch circuit
7.42 2
Business name: Full ru lv�.41'4 V t e ' i t 1/ B. Fee for branch circuits
/ � (� ` `' without service or feeder fee,
Contact name:
/'l/t 4 r (/.--- ��1 Gil first branch circuit 56.18 2
Address: j 3 ��'1 Ski. e / 77 C I(j Each add'1 branch circuit 7.42 2
ty � i L / ' q7 �Z Miscellaneous (service or feeder not included)
Ci / State /ZIP: [ /7-- e Each manufactured or modular
dwelling, service and/or feeder 67.84 2
Phone: ( ) ~f /fo _ 17 -(P /// Fax:: ( ) Reconnect only 67.84 2
E -mail: Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting mil- 67.84 i jp$ 2
Signal circuit(s) or limited -
Business name: A energy panel, alteration, or
E Si�jLt � � � t it A-- - '�p -
Address: t] � L . 69(1/)14/ /et - v � - -7 extension. Describe: Page 2 2
S I
t' a t Each additional inspection over allowable in an
City/State /ZIP: � � Q � k Az- �� �� P any of the above
Per inspection 66.25
Phone: (5 -b3 ) 7 - Z4 6 U Fax: (sip ) _ --„cg / 3 Investigation per hour (1 hr min) 66.25
CCB Lic.: /63 y/JZ) Electrical Lic.: ' 6 - 5 1,3 Suprv. Lic.: 3'S G Industrial plant per hour 78.18
f
JO t t` ELECTRICAL PERMIT FEES
• Suprv. Electrician s required: Subtotal:
: /� /) J b y .w Date: O� Plan review (25% of permit fee):
Print name
G (v‘ I I - Z S- State surcharge (12% of permit fee):
/L- Z 14,
This Authorized signature: �1YY TOTAL PERMIT FEE: /,S7 ,
/ This permit application expires if a permit is not obtained within 80
Print name: LVI Z g j� Date: // j -Ol 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( I Ii05 /COM'WEB