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Electrical Permit Application 0 o l _ ii `. =' l� .r ' '
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%`''�`�-�� City of Tigard �
t £ , , - V 'I�'.. o f Permit Permit , N0.. ei.e , . ,, 13125 SW Hall Blvd., Tigard, OR 97223 R E E
Plan Review
'a C ,,, Phone: 503.639.4171 Fax: 503.598.1960 Other • - .. 't
Da te/By:
In Line: 503.639.4175 NO V 200
,T 1 G A R D. Date Ready /By: .1 ; . A 21 See Page 2 for
3, ' °`• "t 7 : -. Internet: www.tigard- or.gov Notified/Method: / Supplemental Information
CITY OF TIGARD
TYPE OF WORlgUIR DINin nIVISION 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 0 Building over three stories.
❑ Demolition ❑ Other:
where the available fact current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or D Floating buildings.
less to ground, or exceeds 14,009 ❑ 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 of75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived systerr
f ❑ Addition of new motor load of ❑ "A" "E , ` 1_Z^ "1_g ,
Job no.: I Job site address: 9304 SW Coral St G L� 100HP or more, occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard/OR/97223 0 Health -care facilities. ❑ Supply voltage for mom than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: l Project name: Coral Commons ❑ Service or feeder 600 amps or more.
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: I Lot no.: [.000 sq. ft. or less 145.15 4
E. add'! 500 sq. ft. or portion _ 33.40 I
Tax map/parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. 0.) 75.00 2
Limited energy, multi - family
' New Single Family Construction residential (with above sq. fl.) 75.00 2
Services or feeders installation, alteration. and/or relocation
200 amps or Tess 80.30 1 2
® PROPERTY OWNER ❑ TENANT 20] amps to 400 amps 106.85 I 2
Name: Coral Commons, LLC 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: 1905 SW 257 Ave. Over 1,000 amps or volts 454.65 2
City/State/Z1P: Troutdale/OR/97060 Temporary services or feeders installation, alteration, and/or
relocation
Phone: (503)666-4240 Fax: (503)666 -2408 200 amps or Tess 66.85 I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449 670, and 701. 401 amps to 599 amps 133.75 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
® APPLICANT 1 ❑ CONTACT PERSON above service or feeder fee,
each branch circuit 6.65 2
Business name: Coral Commons, LLC B. Fee for branch circuits
without service or feeder fcc,
Contact name: Dean Grey 46.85 2
first branch circuit
•
Address: 1905 SW 257 Ave. Each addi branch circuit 6.65 2
Miscellaneous (service or feeder not included)
City /State/ZIP: Troutdale/OR/97060 Each manufactured or modular 9 0.90 2
dwelling, service and/or feeder
Phone: (503) 666 -4240 Fax: : (503) 666 -2408 Reconnect only 66.85 2
E -mail: Pump or irrigation circle _ 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name: Schroeder & Sons Electric Signal circuit(s) or limited-
energy panel, alteration, or
Address: PO Box 748 extension. Describe: Page 2 1 2
City/State /ZIP: Boring/OR/97009 Each additional inspection over allowable In any of the above '
Per inspection 62.50
Phone: (503) 658 -3369 I Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lic.: 49027 Electrical Lic.: 3 -385C Suprv. Lic.: 41525 Industrial plant per hour 73.75
r ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
Print name: Donald Schroeder Date:
Plan review (25% of permit fee):
• State surcharge (t;% ofpermit fee):
Authorized signature: TOTAL PERMIT FEE:
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.
t:\ Building \Permas'ELC- Pern,itApp.doc 05!23/06 440- 4615T(1IAS/COM/WEB
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7
o Building Division
Request for Permit Action
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: n Owner ❑ Applicant ❑ Contractor ig, City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) (//4- .
V 0 I 111 Mailing Address:
City /State /Zip:
��1 7 Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
fl REFUND PERMIT FEES (attach receipt, if available).
f l INVOICE FOR FEES DUE (attach case fee schedule and explain below).
f l REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
✓ ✓
Permit #: ei-- A604)— / DDLQ33 i 434 0 60S .• 40310
Site Address or Parcel #: 9 ./08 93e'/ 93a 9u) ii.u. .,:%
Project Name: 0061 dor/t`/O,J5
Subdivision Name: 0419 dcr - 'e'AJ j Lot #:
EXPLANATION: (}1 /1 Pm_ 1-i Go e e. L- C2f/9- f 9` 45.56e g TJ
V,e %ff E /I E /�<_ (Ex-- ea0o7— oo / l 9� z 93 .4. i✓o
he5 w_-,Q e_ 6,J i, o?✓ �tg5 E Pg/_H/ 75 .
Signature: \
- Date: 7 45 7
Print Name:
—
1 . DF.6 Si L A i
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°.'o 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.
c) not more than 80 % of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) not more than 80 °'o of the building permit fee for issued permits prior to any inspection requests.
2. Refunds
t i a � will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
r' �V1 "F „Yt. 1 S � t..'.
:�Y;. ErNs f�. s F.O R OFFIC U S ONLYs . ` . : `E N
Rte to Sys Admin: Date B Rte to Bldg Admin: Date F ( A 7 '7 By /r'" '
Refund Processed: Date A// ' By Invoice Processed: Date By
Permit Canceled: Date J / /'c i By „ - Parcel Tag Added: Date By
Receipt # Date Method Amount $
1:\ Building \Forms \Re0PermitAction.doc Rev 05/24/06