Permit '': CITY OF TIGARD ELECTRICAL PERMIT
Permit #: ELC2010 -00182
COMMUNITY DEVELOPMENT
`" 1312 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/20/2010
vTIGA 9 Parcel: 2S101 BB01400
Jurisdiction: TIGARD
Site address: 12110 SW GARDEN PL, BLDG# 4
Subdivision: PARK 217 Lot: 0
Project: Randstad
Project Description: Add circuits for moving and adding outlets
Owner: FEES
WALTON CWOR PARK BC 8 LLC Quantity Description Date Amount
BY TTA/EPROPERTYTAX DEPT 325, PO BOX
4900 5 crt Branch Circuits 04/20/2010 $85.86
wo /Purchase Service or
PHONE: Feeder
1 ea 12% State Surcharge - 04/20/2010 $10.30
Electrical
Contractor:
JEROME ELECTRIC
PO BOX 751
HILLSBORO, OR 97123
PHONE: 503 - 648 -5144
FAX: 503 - 648 -9723
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $96.16
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 if 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 OAR 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: lak "/ "" `^ ``
ui Permittee Signature: � f�i
( OWNER INSTALLATION ONLY 0
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.
04/15/2010 09:13 5036489723 ' JERMOE ELECTRIC INC PAGE 01
Electrical Permit Application QpR 5. . 1 , d, , Fc� < I( � tllF Or ' li
t a r Received
- ,, , Cit o f Tigard Date/13y: __ Permit No. 646, / D - 00 f ga —
s ",, 1 3 1 2 5 SW H .�°++1' Tigard, OR 97223 OF T1GNI Pl R
�. -• y Phone: 503,639.4171 Fes: 503.598,040 /-� �1 Other Permit.
:, rYYarprachf9t7tfJ Internet! www,tigard- or.gov
NiM °''' inspection Line: 503,639.4175 �U11 ate Ready/By; Mitt M See Page 2 for
k7tGA'RU: N 1" V Supplemental Information
_
TYPE OF WORK PLAN REVIEW
❑ New construction IF: Addition /alteration /rcplseement
Please cheek all that apply (submit; sets of plant w /items checked below).
❑ Service or feeder 400 amps er more ❑ Building over three stories
Q Demolition El Other: where the availabie fault current ❑ Marinas and bontynrd
RY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or En Floating buildings,
_ _i _. CA Icsa 10 ground, or exceeds 14,000 ❑ Commercial use agricultural
q � ; ' ;'. - and 2 - family dwelling ommercial /industrial [] Accessory building amps Par an other installations. buildings,
1 Multi - family - • Master builder 0 Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger sepnrntely derived system.
JOB surf INFORMATION AND LOCATION 0 Addition anew motor load of
� _ {�7 1001-1P or more. occupancy.
lob no.: Job site address: 4 4 ] . ❑ Six or more residential units. 0 Recreational vehicle parks .
r n ID faculties. Cl Supply voltage far more than
City/State/ZIP: l f / T ' l _ (D Hazardous locations. 600 volts nominal
❑ Service or feeder 600 amps ar more.
Suite/bldg./apt. no.: Project name: FEE SCHEDULE
Cross street/directions to job site: _ g o . _ Derrrt Lion L•t , Fee. Total •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Lot no.: 1,000 sq, ft. or loss 168.54 4
Subdivision: Ea. add') 500 sq, ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential 67,$4 2
DESCRIPTION OF WORK with above s.. a.
Limited energy, multi- family 67,84 2
.' • l � Er ill • j•o� • • ) residential (with above sq. n.)
ti Services or feeders Installation alteration and/or relocation
e'i-kt t,er 200 amps or less 100.70
in PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56
401 amps to 600 amps 200.34
Name; 601 amps to 1,000 amps 301.04
Address: Over 1,000 amps or volts 552.26 7
Temporary services or feeders installation, alteration, and /or
City/State/ZIP: relocation
Fax: ( ) 200 amps or less 59.36 1
Phone: ( ) 125.08 2
201 amps to 400 amps
Owner installation: This installation is being made on property that i own which is not 401 amps to 4 00 amps 168.54
intended for sate, lease, rent or exchange, according to ORS 447, 449. 670. and 701. Branch circuits new, alteration, or extension, per panel
Owner signature: D:ttc - A. Fcc for branch circuits with
❑ APPLICANT 0 CONTACT PERSON above scrvicc or feeder fcc, 7,42 2
each branch circuit
Business name: 6. Fcc far branch circuits
without service ar feeder fee, 1 56 18 ._.l
• r'' 2
Contact name, _ first branch circuit
Each add'I branch circuit d" • 7.42 2
Address: Miscellaneous service or feeder not included)
City /Slatc/ZIP: Each manufactured or modular 67,84 ).
dwclllnI, service and /or feeder
2
Phone; ( ) Fax: ; ( ) Reconnect only 67.84 2
Email: Pump or irrigation circle 67.84 -
CONTRACTOR
Sign or outline lighting 67.84 — 2+ 1
Signal circuit(s) or limitcd-
I3usinCSS name: 0 i Ad I ,, I Y\ energy panel, alteration, or Page 2 2
6
Address: - `, 1...„ extension. Describe: � 1 -
wr do 1 2 Each additional Ins pection over allowable in an of the above
City /State /ZIP iI �V L Pcr inspection 66.25
Phone: (� 4 .4 A Fax: ( .. ► — nvcctigatiOn per hour (1 hr min) 66.25
`r"`� ��
- �/ industrial plant per hour 78
CCB LiC.: h
t ��. ELECTRICAL PERMIT FEES
. Subtotal;
Suprv. Electrioia 'i:.natur , quircd:
Print name: Date 0 permit fee):
State review (25% of e surcharge (i2 %of permit fcc); P i
. t ^ '�� �� '
�
Authorized signature: TOTAL PERMIT PEG: 9.(49. (4) TNIs permit imputation 1( permit is not obtained within ISU
Date: days after it bag been accepted M campietc.
Print name: • Number of Inspections nitawed per permit.
140-4615111 l,os!COM+K'
1 \ Nt ildinnU'ermital-C•PermitApp.doe 10/01109