Permit J U ! ! ,, CITY OF TIGARD ELECTRICAL
.x COMMUNITY DEVELOPMENT Permit #: ELC2010 -00191
IGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 04/21/2010
Parcel: 2S102AA05500
Jurisdiction: Tigard
Site address: 12215 SW MAIN ST
Subdivision: Lot: 0
Project: Tigard Fitness
Project Description: (10) branch circuits for TI
Owner: FEES
CHOI, WOO Y & Quantity Description Date Amount
CHOI, MAN JA, 2323 NE 165TH DR
PORTLAND, OR 97230 10 crt Branch Circuits 04/21/2010 $122.96
wo /Purchase Service or
PHONE: Feeder
1 ea 12% State Surcharge - 04/21/2010 $14.76
Electrical
Contractor:
TRINITY ELECTRIC
13422 SW 128TH PL
TIGARD, OR 97223
PHONE: 503 - 235 -6481
FAX: 503- 579 -3929
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $137.72
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 • - /.` 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: �1 /0
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.
Oc dv- Q' >i5•1
;1 Community Development
RECFIVED
Request for Permit Action
TIGARD APR.2 2010
CITY OF TIGARD
TO: CITY OF TIGARD BUILDING DIVISION
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 ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) 7 M • .././y C/Pr' it- ; (,
Mailing Address: / 34,. S iv [...lel% pi_ .
City/State /Zip: "T &ro nR 1 l x-1-3
Phone No.: / — — '-- 3.< — ,6(/, 6
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): � -r( 0 . d i>
CANCEL PERMIT APPLICATION. \ ; fJ� Of V�
REFUND PERMIT FEES (attach receipt, if available). (j) ei f_
INVOICE FOR FEES DUE (attach case fee schedule and explain below). (" ' 4111 ' () Q
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). (( I
10
Permit #: EL C -2010- on /
Site Address or Parcel #: / . Lc 5i/i/ Ma; n c . - rid r I OR
Project Name: 7 , 9a rd 1
Subdivision Name: Lot #:
EXPLANATION:
Own-.r clops/1't wan ,
Signature: ) Date: L / h 0
Print Name: in S , r' -
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.
e) 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. 1
FOR OFFICE; USE: ONI.V
Rte to S s Admin: Date B Rte to Bld • Admin: Date /Q MA= B
Refund Processed: Date A/ B .: i7' Invoice Processed: Date B
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt # Date Method Amount $
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City o Tigard Rece Date x / /0 �IO / Permit No.:a_C a/D —/q
�
q 13125 SW Hall Blvd., Tigard, OR 2 t010 Plan Review /
C ,.. Phone: 503.639.4171 Fax: 503.5 1 0 Date /By: Other Permit:
I'ti A It I ) . Inspection Line: 503 Date Read /B Juris. ® See Page 2 for
-_ _ Internet: www.tigard-or.gov CITY OF TlGAR� Notified/Method: ( lj Supplemental Information
TYPE N6ta DIVIS!C'Yr PLAN REVIEW
❑ New construction X 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 ", "1 -2 ", "1 -3 ",
'(- , . / �/J 9. 100HP or more. occupancy.
Job no.: Job site address:
1 �2 SW /' `aI "7 /T - ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: T�� r � �1 ❑ Health -care facilities. ❑ Supply voltage for more than
J (/ 0 Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: q t rot ❑ Service or feeder 600 amps or more.
f�jj ' ' ��� 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. 0 or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
sq. 67.84 2
DESCRIPTION OF WORK ( with above 4 fi. )
Limited energy, multi - family 67.84 2
4 /J
! / 5 / t/; ,/ // /_'g_y , 4)7d / P/y residential (with above sq. R.)
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
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
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
El -APPLICANT ❑ •CONTACT, PERSON above service or feeder fee, 7.42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 �� II? � 2
Contact name: branch circuit r
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder of included)
City/State/ZIP: /State /ZIP: Each manufactured or modular 67.84 2
Y dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited - energy
Business name: 19 panel, alteration, or extension. Page 2 2
/�/ �tt? ``f � Each additional inspection over allowable in any of the above
Address: J 34 . . 5 %i I 71/1 pt. • Additional inspection (1 hr min) 66.25/ hr
City/State/ZIP: Investigation (1 hr min) 66.25/ hr
Y T ,i a re (7 , ��y� Industrial plan (1 hr min) 78.18/ hr
Phone: ( /,' /)._� ._ (g / Fax: �3 - -- 2 s� Inspections for which no fee is 90.00 / hr
9 spesif+eally listed (/: hr min)
B Lic.: /..4 3 9 � El ctrical Lic.: 3 Suprv. Lic.: 4 z !� ELECTRICAL PERMIT FEES
Suprv. Electrician signnailfe, 4 u�red: _ o Subtotal: j,� r j (,
_ Plan review (25 /o of permit fee):
Print name: i S' � ,, Date: 4/,, `/ r2 State surcharge (12% of permit fee): /`/ .7 ,
-+ / / TOTAL PERMIT FEE: /37 72,
Authorized signature:
T his permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: 1" / /7,c__ Date: 44_00 • Number of inspections allowed per permit.
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I:\ Building \Permits \ELC- PermitApp. doc 10/01/09 440- 4615T( I I /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*
n Burglar Alarm
❑ Garage Door Opener*
❑ 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:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑
•
Protective Signaling
❑ 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