Permit • •
Hr ,�, CITY OF TIGARD
ELECTRICAL PERMIT
a . COMMUNITY DEVELOPMENT Permit #: ELC2009 -00568
_;, k4 Date Issued: 10/27/2009
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
= Parcel: 1 S 133DA02100
Jurisdiction: Tigard
Site address: 11043 SW SUMMER LAKE DR
Subdivision: Lot: 0
Project: Bank of New York
Project Description: Reconnect.
Owner: FEES
BANK OF NEW YORK Quantity Description Date Amount
400 COUNTRYWIDE WAY SV -35
SIMI VALLEY, CA 93065 1 ea Reconnect Only 10/27/2009 $67.84
1 ea 12% State Surcharge - 10/27/2009 $8.14
PHONE: Electrical
Contractor:
SIMPSON ELECTRICAL CONSTRUCTION
2145 NE MCDONALD LN # C
MCMINNVILLE, OR 97128
PHONE: 503 - 472 -2530
FAX: 503 - 435 -0157
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 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: 0 .\ - . 1 I A • ♦ . w Permittee Signature:
NW 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' n n Date:
0 CX AO r
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.
k '6 CEIVED
Electrical ( Nile'iz .. ') , tvgm'r `i`i k O R G F ?mtwgriv S C U f l l ' a y' g+`�' r� lH " ,F+t�)'4� � t
Permit Application ,.. Ir . , .ta liti ._t _,g: ut t t :' faul �s :s
rin,1744 0 C T 2 3 2009 Received City of Tigard Date : In �!N r • •
� ..rq 13125 SW Hall Blvd., Tigard, OR 97273
g Platt Review
t.
B), - - 1R. Phone: 503.639.4171 Fax: 503.598.19 OFTIGARD Qateist: Outer Permit:
- d 1 t"'''f='1 si" A Internet www.tigardor.gov
Inspection Line: 503.639.4175 BU ILDING DIVISION
imsras ra:.
Date Ready/13y: r,rr� la See Pape 2 for
gat k:D Notihed/tv!ethod: , Supplemental Information
lse
TYPE OF WORK • PLAN REVIEW
❑ New construction I. Addition/alteration /replacement Please check all 11! r apply (submit 2 sets of plans vslitenu checked below':
0 Service or fe -.:. 400 amps or more 0 Building over three stones.
❑ Demolition ❑ Other: where the avai L blc fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION excueris 10,001 arcps at 150 volts or 0 Floating buildings.
less to Igeuttd. • exceeds 14,000 ❑ Commercial -use agricultural
0 , and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all otjer irstaaations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fife pump. . ❑ Installation of 75 K V A ar
❑ Emergency sy cm. larger separately derived system.
JOB SITE INFORNIATION AND LOCATION ❑ Addition of n motor load of ❑ "A "E", "1- 2 ", "1 -3'.
100HP or mor :. occupancy.
Job no.: Job site address: I joy 3 S� , t'iCs.( ,2 De.
1 ❑ Six or more r i 'dential units. ❑ Recreational vehicle parks.
City /State/7.1P: 1 " 0 Health -care fa' ilitim. ❑ Supply voltage for more than
( tr'a G ! r� Q ❑ Hazardous loc eons. 6J0 volts nominal.
Suite /bldg.apt. no.: 7 Project name: ❑ Service or fcc f cr 600.wnps or more.
FEE SCHEDEILE
Cross street/directions to job site: toeseri ion CCS F. —.
Total
New residenti :1 single- or multi-family dwelling unit.
includes attac ed garage.
Subdivision: • Lot no.: 1,000 sq. ft. or!ess 145.15 j 4 1
Ea. add'I 500 :t. fL or portion 33.40 1
Tax map/parcel no.: -
• Limited ener • residential
75.00 2
DESCRIPTION OF WORK • (with abu'e . R.)
Limited energ . multi- family E 75.00 f 2
5ert1L CC, ireCan.A eC _ residential (• * thabove sq. ft.) I t
Services or feeders installation. alteration, and /or relocatio
200 amps or I . s 80.30 i 2
❑ PROPERTY OWNER , . ❑ TENANT 201 amps to 4'4,0 amps 106.85 2
401 amps to 6i 0 amps 160.60 2
Name:
601 amps to 1 ,1 10 amps 240.60 2
Address: I Over 1,000 a ' or volts , 454.65 2
Ci fState /ZIP: Temporary s ;rvkes or feeders installation, alteration, and/or
ty relocation
Phone: ( ) Fax: ( ) 200 turps or 1 66.85 1
Owner installation: This installation is being made on property that 1 own which is not 201 amps to 4,10 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. l 401 amps to 5,' 9 amps 133.75 2
Branch circu, s— new. alteration. or extension, er .anel
Owner signature: Date: A. Fee for bra' ch circuits with
❑ APPLICANT ❑ CONTACT PERSON . above stxv' c or feeder fee, 5 2
6.6_
each branc circuit -
-
Business name: B. Fee for bra' ch circuits I
without se ice or feeder fee,
46.$5 2
Contact name: first branc circuit
Address: Each add't b ; ch circuit 1 6.65 , , 2
Miscellaneo : (service or feeder not included)
City /State/ZiP: Each manufa•tured or modular I' _ 90.90 1 2
g
dwellin. se ;ice and/or feeder ! Sy
Phone: ( ) I Fax: : ( ) Reconnect on v 1 / 2 j
E -mail: Pump or irri_ +lion circle ' 53.40 2
CONTRACTOR Sign or outli lighting 53.40 2
Signal cireui i, st or limited -
Business name: Sl m(E� n � p 1�� t( ` � � /7 struLQ energy panel alteration. or
Address: ait.i uG t y f 4
11 ,,, C C �1 extension. D�.cnbe: Page 2 2
y �,, ra id_ � J +/)
City/Statc/ZIP: / 2 • ; Each additi t a t ins over allowable i a ny of the above
Per inspecti I 62
Phone: (50:1 472.- 2- ? Fax: (3) 435 — 1 67 Investigation per hour fl hr min) 62.50
CCB Lic.: i 538 Electrical �-8 c_ Suprv. Lic.: C as Industrial pi' t per hour I 73.75 1
I ELE PERMIT FEES
Suprv. Electrician signature, required: 1 Subtotal: ' "° '
/ Plan review (25% of permit fee): ----- Print name: { / Date: �0/ 3 i 0 �` S to surcharge (12% ofpermit fee): �� . d• 14
Authorized signature: � + - TOTAL PERMIT FEE:
This permit pplication expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complNe— ^
• Number o espections allowed per p:rmit. ' l le. 9,
I:43u iI 5'J cr mit 1 05(23/(16 4.10 -06151(11105 /COMJWF
L. ' d LSI. 0 NOSdINI NIA2>i 8 LC :60 60 £Z PO