Permit ,i a CITY OF TIGARD ELECTRICAL PERMIT
71
a: COMMUNITY DEVELOPMENT Permit #: ELC2009 00604
T j G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/12/2009
Parcel: 1S136CA04000
Jurisdiction: Tigard
Site address: 11170 SW 79TH AVE
Subdivision: FRIENDLY ACRES Lot: 8
Project: Palcic
Project Description: Ground service after change to water piping.
Owner: FEES
PALCIC, LILLIAN S Quantity Description Date Amount
11975 SW KING JAMES PL
KING CITY, OR 97224 1 crt Branch Circuits 11/10/2009 $56.18
wo /Purchase Service or
PHONE: Feeder
1 ea 12% State Surcharge - 11/10/2009 $6.74
Electrical
Contractor:
WILLAMETTE ELECTRIC INC
PO BOX 230547
TIGARD, OR 97281
PHONE: 503 - 624 -3631
FAX: 503 - 624 -2938
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $62.92
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: r ..& .. ` _ . _ ♦ 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' \ Q )-�r 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.
• 1100/2009 TUE 10:02 FAX 5036242938 Willamette Electric Z002/002
Electrical Permit Applicat EC V ED FOR OFFICE USE ONLY
Clt o Tigard Received PermitNo
Y g N J V i o 2009 Re a ive F iC2(')n9 -�
17 t 13 125 S W Hall I31vd., Tigard, O 972 Plan Review
• Phone: 503.639.4171 Pax: 503.598.1960 Datef3y: Other Permit: A 1712001.
TIGARD
Ins l..me: 503.639.4175 CITY OF TIGARD Date Ready /By: lurk: to see Page 2 for `�
Internet: www.tigard- or.g °v BUILDING DIVISION Notified /Method: e Supplemental Information
..._
TYPE OF WORK PLAN REVIEW
❑ New construction ®Addition /alteration /replaccmcnt
Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or (ceder 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
❑X 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
❑ Emergency system. larger separately derived system.
J013 SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑' A" "f "' ' t •2" ° I -3"
Job no.: 5189 Job site address: 11 SW 79 Ave IOOI IP or more. occupancy.
❑ Six or more residential units. ❑ Rccicalional vehicle parks.
City /State /ZIP: 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ I lazardous locations. 500 volts nominal.
Suite /bldg. /apt. no.: Project name: Palcic ❑ Service or feeder 600 amps or snore.
— -
FEE SCHEDULE
Cross street /directions to job site: Description 1 _ 1 . i - __rP
• - New residential single- or multi-family dwelling unit.
Includes attached garage.
Subdivision: 1.ot no.: 1,000 sq. f1. or Tess 145.15 4
- Ea. add'I 500 sq. B. or portion 33.40 t
Tax neap /parcel no.: Limited energy, residential
(with above sq. ft. 7 2
DESCRIPTION OF WORK (
141 q. )
Limited energy, multi- family 75.00 2
ground service after water main was replaced residential (with above sq. R.)
-_ Services or feeders installation, alteration, and /or relocation
�__ 200 amps or less iY _ - -ge.3b ff _2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
- -. - -.- -- 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/State/ZAP: Temporary services or feeders installation, alteration, anti /or
relocation
Phone: ( ) Fax: ( ) 200 amps or Icss 66.85 I
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 10030 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
❑ AI'PLICANT — ❑ CONTACT PERSON above scrvicc or feeder fee, 6.65 2
— - each branch circuit
Business name: B. Fee for branch circuits
without scrvicc or feeder fee, 1 �
Contaact ct name: I
S• 18 2
a
first branch circuit
Address: Each add'I branch circuit 6.65 2
.- ...... . ... ..._..__ Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 90.90 2
dwelling, scrvicc and /or feeder
Phone: ( ) —^ i Fax: : ( ) Reconnect only 66.85 2
E-mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2_
Business name: Willamette Electric Inc Signal circuit(s) or limited-
energy panel, alteration, or
Address: PO Box 230547 extension. Describe: Page 2 2
City /State /ZIP: Tigard OR 97281 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (503) 624-3631 Fax: (503) 624 -2938 lnvestigalion per hour (I hr min) 62.50
CC)3 E.ic.: 75059 Electrical Lic.: 34 -283C Suprv. Lic.: 4226S Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: f --•� — _ Subtotal: • 2
Plan review (25% of permit fee):
Print name: David Fife Date: 10NOV09 - { -7'l
Slate surcharge (12% of permit fec): L,[ "I
Authorized signature: TOTAL PERMIT FEE: .mi
— This permit application expires if a permit is not obtained within 180
Print name: Date: clays after it has been accepted as complete. 9
Number of inspections allowed per permit. (02,
1 1Duuds 5 ".Permits \EEC- PennaApp.doc 05/23/05 4.10- 40151(11 /05 /COM /WEI3
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