Permit •
ti CITY OF TIGARD ELECTRICAL PERMIT -
RESTRICTED ENERGY
Ahgo , DEVELOPMENT SERVICES PERMIT #: ELR2003 -00004
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/10/03
SITE ADDRESS: 12750 SW 68TH AVE PARCEL: 2S101AD -01300
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT: 033 JURISDICTION: TIG
Protect Description: Thermostats to 4 separate units.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: : HVAC: X PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
TOTAL # OF SYSTEMS: 4
Owner: Contractor:
HAMPTON BUILDING, THE LLC ACCURATE HEATING
PO BOX 94 PO BOX 2276
CAMP SHERMAN, OR 97730 CLACKAMAS, OR 97015
Phone: 5541 -595 -2495 Phone: 503- 650 -1229
Reg #: LIC 88423
ELE 3- 384CEP
SUP 2617LEP
FEES Required Inspections
Description Date Amount Wall Cover
[ELPRMT] ELR Permit 1/10/03 $300.00 Low Voltage Inspection
Elect'I Final
[TAX] 8% State Tax 1/10/03 $24.00
Total $324.00
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and
all other applicable laws. 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 than 180 days. ATTENTION: Oregon law requires
you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 -001 -0010 throuc
Issued by 1 � / � / 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'N DATE:
LICENSE NO: 3 - 3 L ( ( F.
Call 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Electrical Permit Application FOR OFFICE USE ONLY
Received ,sio i, Electrical rr
° Date/By: t _ j 0 — 0 3 Permit No.FL 6,7006
City Tigard Planning Approval Sign
ty g Date/By: Permit No.:
13115 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503-598-1960 i0,907 Post - Review Land Use
M. l { II
�
Contact Case No.:
Internet: www.ci.tigard.or.us ■ el Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 "- Name/Method: Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
®. Addition/alteration/replacement 111 Other: ❑ Service over 320 amps- rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
❑ 1 & 2- Family dwelling 15t Commercial/Industrial ❑ System over 600 volts nominal one structure
❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building U Multi- Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit _ sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: /2750 51, 611' AI pe% i 4 FEE* SCHEDULE
Suite #: I Bldg. /Apt. #: Number of inspections per permit allowed
Project Name: N. Srn cr► SGyI Description Qty Fee (ea.) Total
New residential - single or multi - family per
Cross street/Directions to job site: dwelling unit. Includes attached garage.
Service included:
1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Subdivision: 1 Lot #: Limited energy, residential 75.00 2
Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
CS/) T f '� Services or feeders - installation,
1 e fY .fil / lir 1 /. 7a 7� alteration or relocation:
C/ (� 200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
❑ PROPERTY OWNER I ❑ TENANT 601 amps to 1000 amps 240.60 2
Over 1000 amps or volts 454.65 2
Name: Reconnect only 66.85 2
Address: Temporary services or feeders - installation,
alteration, or relocation:
City /State /Zip: 200 amps or less 66.85 I
Fax: 201 amps to 400 amps 100.30 2
Phone: 401 to 600 amps 133.75 2
N APPLICANT 2 � � CONTACT T PERSON Branch circuits - new, alteration,or
Name: �lt t 1 1JI AG tit r4 `) . extension per panel:
1--.1.--) A. Fee for branch circuits with purchase of
-6,c, j � ,�
Address7Pv X service or feeder fee, each branch circuit 6.65 2
City /State /Zip: e( A C. \C-A -, 4N (r2 cl'7 p / j B. Fee for branch circuits without purchase of
J service or feeder fee, first branch circuit 46.85 2
Phone: (or ) /L7 Fax: Gsa <' Z �/S Each additional branch circuit 6.65 2
E -mail: /II A/ ckeA r, 7R caeca /Aie t f 4 • Cu'■' Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2 _
Job No: Signal circuit(s) or a limited energy panel,
alteration, or extension Page 2 2
Business Name: Ace L. ( + - (>(e g b, Description: _
Address: ,, ao.k 7-214
Each additional inspection over the allowable in any of the above:
City /State /Zip: C.A-e. /t Ain 4 S 62 1 - )0 1-1 Per inspection per hour (min. 1 hour) 62.50
Phone: S . G 5"o 12 27 Fax: - 0 • y8ys Investigation fee:
CCB Lic. #: /4 J Li . #: 2 G 17 - bee Other: Electrical Permit Fees*
Supervising electrician ati- Subtotal $ 300 OO
Plan Review (25% of Signature required: Permit Fee) $
Print Name: !Lein V lo a Lic. #:1-W� State Surcharge (8% of Permit Fee) $ 44. UD
TOTAL PERMIT FEE $ 3a.1-1 . 00
Authorized Notice: This permit application expires if a permit is not obtained within
Signature: Date: 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
-- (Please print name)
is \Dsts\Permit Fotmms\ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
•
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
Audio and Stereo Systems
O Burglar Alarm
El Garage Door Opener
Heating, Ventilation and Air Conditioning System
Vacuum Systems
• Other
COMMERCIAL WORK ONLY:
Fee for each system $75.00
(SEE OAR 918 - 260 -260)
Check Type of Work Involved:
Audio and Stereo Systems
❑ Boiler Controls
▪ Clock Systems
• Data Telecommunication Installation
O Fire Alarm Installation
HVAC
Instrumentation
Intercom and Paging Systems
Landscape Irrigation Control
El Medical
Nurse Calls
Outdoor Landscape Lighting
Protective Signaling
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
iADsts\Permit Forms\ElcPermitAppPg2.doc 01/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line* (503) 639 -4171 MST
BUP L/4
Received ��77 Date Requested p AM PM BUP
a`
Location / '1.� I 11' Suite MEC
Contact Person Ph ( ) /ZZ/ PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Ftg Drain Access: ELR --63
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
- d)K —
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
ASS PART FAIL
SITE Please call fo ' rein .ection RE: Unable to inspect – no access
Fire Supply Line
ADA
Approach/Sidewalk Date Inspector Ext
Other:
Final DO NOT REMOVE this inspection record rom the Job site.
PASS PART FAIL