Permit CITY OF TIGAR® ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2010 -00297
Date Issued: 06/16/2010
�t rop 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S102CC00500
Jurisdiction: Tigard
Site address: 13500 SW PACIFIC HWY 92
Subdivision: Lot: 0
Project: Fantastic Sam's
Project Description: Reconnect only.
Owner: FEES
13500 PACIFIC CORP Quantity Description Date Amount
BY CAPOZZOLI ADVISORY FOR, PENSIONS
INC, 21500 HAGGERTY ROAD, SUITE 100 1 ea Reconnect Only 06/16/2010 $67.84
PHONE: 1 ea 12% State Surcharge - 06/16/2010 $8.14
Electrical
Contractor:
OWNER
PHONE:
FAX:
Type of Use: COM
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 folio • - adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OAR 952- 001 -0100. You ma obtain - • or direct questions to OUNC by - • I . :00.332.2344. '
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:
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.
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Electrical Permit Application 0,1 � r t yt
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III City of Tigard OC.') DateB 4 { 10 Permit No.:
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13125 SW Hall Blvd., Tigard, OR 97223 Plan Review , �” ) (�
10 ;, Phone: 503.639.4171 Fax: 503.598.1960 16 ` \ Date/By: Other Permit: (r) -_,�, i1
I I t n R A\ D Inspection Line: 503.639.4175 ,� \V . i e Ready/By: : luris: � See Page 2 for
! .., Internet: www.tigard- or.gov +� X0 e lhod: "�T� Supplementa Information
TYPE OF WORK �� � �� ���
r . PLAN REVIEW
� t , Cl
❑ New construction ❑ Addition/alteration/repl i11i Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stones.
❑ 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
0 Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
1 'ti ry I C ? 7 I00HP or more. occupancy.
Job no.: Job site address:
,t ti J G L kl {�4 < i �'tC. I•J • ' 9 . L S ix or more res •
un ❑ Recreational vehicle parks.
City /State /ZIP: fit' - Gt. i CIb C' 225
❑ Health -care facilities. Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: ,i� Project name: 1 I� r!� 0 or feeder 600 amps or more.
l \ FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I 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'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
67.84 2
• DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family 67.84 2
re C.cfl 1 :" (j �� �y � L - i -e-4^� residential (with above sq. ft.)
3 Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER 0. TENANT 201 amps to 400 amps 133.56 2
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6)6:440 / j ,!� 401 amps to 600 amps 200.34 2
Name: (. Sk 6�' 1. aft I 1 � - �L - 3 I ✓)C. 601 amps to 1,000 amps 301.04 2
Address: 1 (j I j ji.. ci t $C 'v s Over 1,000 amps or volts 552.26 2
L Temporary services or feeders installation, alteration, and/or
City /State /ZIP: P(r +ICLyACIL) e n 9 7 .t relocation
Phone: (.3) ?? 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 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
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 7.42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'l branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
tY dwelling, service and/or feeder
Phone: ( ) Fax:: ( ) Reconnect only I 67.84 67 K y 2
Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
CONTRACT R Signal circuit(s) or limited- energy
Business name: panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18 / hr
Phone: ( ) F : ( Inspections for which no fee is 90.00/ hr
specifically listed (V2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: (Q '7 As-14
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): '' ` i'l
TOTAL PERMIT FEE: 7 - r et
Authorized signatt� T his permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: � L j ri Date: 6 i i ( t 01 c) + Number of inspections allowed per permit.
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I'\Buildin \Permits\ELC- PermitApp.doc 10 /0I /09 440- 4615T(11 M/
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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:
❑ Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
n 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
n Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
❑ Instrumentation
n Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
n Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
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