Permit CITY OF TIGARD ELECTRICAL PERMIT
1111 is • • COMMUNITY DEVELOPMENT
Permit #: ELC2010 00457
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/27/2010
Parcel: 2S 102CA00943
Jurisdiction: Tigard
Site address: 13580 SW VILLAGE GLENN DR
Subdivision: VILLAGE GLENN Lot: 43
Project: Robbins
Project Description: (2) branch circuits to accessory structure.
Owner: FEES
ROBBINS, KEITH D & CYNTHIA K Quantity Description Date Amount
13580 SW VILLAGE GLENN DR
TIGARD, OR 97223 2 crt Branch Circuits 08/27/2010 $63.60
wo /Purchase Service or
PHONE: Feeder
1 ea 12% State Surcharge - 08/27/2010 $7.63
Electrical
Contractor:
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $71.23
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 • ;00.33 .2344. •
Issued By /� % ..�'� ' _ !�_ Permittee Signature: �`w
' 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.
Electrical Permit Application Fall OFFICE IISE ONLY
�
Ill City of Tigard t —_, r . \\; I, ', � Received
DateB : g 7 1 • i
° 13125 S W Hall Blvd., Tigard, OR 9722 ;1�'1 ,, '" "r. �` = ' Plan Review
/OP
' Phone: 503.639.4171 Fax: 503.598. I960;L _ D ateIB : Other Permit:
11 t , i , i , Inspection Line: 503.639.4175 q r! `�Q�Q Date Ready/By: Atria gi See Page 2 for
Internet: www.tigard - or.gov 0 f+ 1 Notified/Method: Q Supplemental Information
TYPE OF WORK rt` ; > PLAN REVIEW
• : > ■ - • s.I , ..
12 New construction ❑ Addition / alteration /I' l.q l `)''' Please check all that apply (submit a sets of plans w /items checked below):
,. � }I,1: i+'•''' ❑ Service or feeder 400 amps or more ❑ Building over three stories.
12 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 :4I 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 ",
Job no.: Job site address: 11 IOOHP or more. occupancy.
3 ,54i1� 5� i\\et `" v ,...– ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP , V ['Health facilities. ❑ Supply voltage for more than
r0�ty ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: ` T Project name: ❑ Service or feeder 600 amps or more.
/� FEE SCHEDULE
•
Cross street/directions to job site: � ` \\ h\ t � \ 4,+. 4, .1,0 x% Description 1 Qty. 1 Fee. 1 Total 1 •
New residential single - or multi- family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft. or less 168.54 4
Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1
Limited energy, residential
c n) 1 vM . �
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi- family
CMSIt j \`n 1 l - SRrc k( ft - •■tN■• C,M) \ �X ! residential (with above sq. ft.) 75.00 2
Services or feeders installation, alteration, and/or relocation
v/Af.Azp`tva, Sh \\ 1400 (- O L tY. .t) Siels\ el) 200 amps or less 100.70 2
. PROPERTY OWNER I 4 ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
�
Name: ‘h Qx1b\\ Yt 1,1,,,,*
1 `` 601 amps to 1,000 amps 301.04 2
Address: \36c€ ,5v1/4 "
0 O (\ � '. c Over 1,000 amps or volts 552.26 2
� Temporary services or feeders installation, alteration, and/or
City/State /ZIP: I)(N \)/ CR... relocation
Phone: (< ) ( _ -- 7s.tr� Fax: ( ) 200 amps or less 59.36 1
Owner installation: This ins . : Lion is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale, lease, ties ; 0 iii` _ , 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: — !I r..,� A , , Date: V I A. Fee for branch circuits with
❑ ® APPL CANT CONTACT PERSON above service or feeder fee, 7 42 2
I each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first I 56.18 5 2
Contact name: 0 4;th Ceb Fes--- branch circuit
Each add'I branch circuit I 7.42 7. k}} 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 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: panel, alteration, or extension. _ _ Page 2 2
�CJ/ll'Gt#' 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: ( ) Fax: ( ) 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: j, CO
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE: 7 /, J-3
Authorized signatu • l i1,'„0e: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: , f , ,,D A/_4 S Date: A 2., ?' J • Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 07/01 /10 44 - 4615T(l1/05 /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 .. $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
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 07/01/10
!,n.
Information Notice to Owners About
Construction Responsibilities
(ORS 701.055 (5))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503 - 378 -4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503 - 947 -1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to
.http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503 - 947 -7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• ._ Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough -in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052
Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007
Website Address: www.oregon.gov /ccb
f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant
,
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and 1 hereby certify that the Information on this homeowner statement is true and accurate.
�1fi )e „....,
Print Nam mit - Applicant I 10 Ti i / ; ~— LI 2 3 ?i.f /, d
Sign - re of Permit Applicant Date
Permit #: i =LD t 0 . —(Ott5 7
Address: I ■ 0 . - • , � ; i S
Issued by: U , T Date: r /a7 /1 0 1.4.
This Copy for Permit Offices