Permit A 7,,, CITY OF TIGARD
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: 1i I DEVELOPMENT SERVICES
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CITY OF TIGARD Electrical Permit Application Plan Check #
13125 SW HALL BLVD. Rec'd By
TIGARD OR 97223 Date Rec'd
Phone (503) 639 -4171, x304 Date to P.E.
Inspection (503) 639 -4175 Print or Type Date to DST
Incom or illegible will not be accepted Permit # �(° - _ 36
Fax (503) 684 -7297 Called
1. Job Address: 4. Complete Fee Schedule Below:
Name of Development Tr A, Ivo k . FkV K core C Number of Inspections per permit allowed
Name (or name of business) U 1 i ) ec i t y o �' Phoen , X Service included: Items Cost Sum
1
Address 1 J /d 61") 613 Lk. Par ucty 4a. Residential - per unit
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City /State/Zip 5st -1 OR. 17223 1 000 sq. ft. or less $110.00 4
Each additional 500 sq. ft. or
Commercial, Residential ❑ portion thereof $25.00 1
Limited Energy $25.00
Each Manuf'd Home or Modular
Dwelling Service or Feeder $68.00 2
2a. Contractor installation only_:
(Attach copy • : I1 current licen s) ' - - - 40 oerviceu oouc.* -
Electrical o ntracto rt l•.:.�... _ • r� • I ns t a ll a ti on, a lt e ration , or relocation - C
fie, 200 amps or less
q � (,U e ) . cfr r n,� $60.00 2
Address /; 7
1 1 2 01 amps to 400 amps $80.00 2
City State Zip 77 2 2 401 amps to 600 amps - $120.00 2
Phone No. -- 24.) 601 amps to 1000 amps - $180.00 2
Job No. iii I� Over 1 Reconnect 0 amps ys or volts only 000 2
Elec. C Lice. No. 1 Exp.Date
OR State CCB Reg. No. ' E Date \ 91 4c. Temporary Services or Feeders
COT Business Tax or Metro No . - xp.Date 1 )91 Installation, alteration, or relocation
200 amps or less $50.00 2
Si Signature of Su r. Elec , 201 amps to 400 am ps $75.00 2
9 P _ 401 amps t o 600 amps $100.00 2
Over 600 amps to 1000 volts,
License No. 1 OS' Exp.Date see "b" above.
Phone No. 5S 3hf)b 4d. Branch Circuits
New, alteration or extension per panel
2b. For owner installations: a) The fee for branch circuits with
purchase of service or 00
Print Owner's Name feeder fee. /, 24/0
Address Each branch circuit `(� $5.0 2
b) The fee for branch circuits
City State Zip without purchase of
Phone No. service or feeder fee.
First branch circuit $35.00 2
The installation is being made on property I own which is not Each additional branch circuit $5.00 2
intended for sale, lease or rent. 4e. Miscellaneous
(Service or feeder not included)
Owner's Signature Each pump or irrigation circle $40.00 2
Each sign or outline lighting $40.00 2
3. Plan Review section (if required):* Signal circuit(s) or a limited energy
panel, alteration or extension $40.00 2
Minor Labels (10) $100.00
Please check appropriate item and enter fee in section 5B.
4 or more residential units in one structure 4f. Each additional inspection over
Service and feeder 225 amps or more the allowable In any of the above
System over 600 volts nominal Per inspection $35.00
Classified area or structure containing special occupancy Per hour $55.00
as described in N.E.C. Chapter 5 In Plant $55.00
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* Submit 2 sets of plans with application where any of the above apply. 5. Fees: / /� (Do
Not required for temporary construction services. 5a. Enter total of above fees $ 1 /i coo
5% Surcharge (.05 X total fees) $ i 6.005
NOTICE Subtotal $
5b. Enter 25% of line 5a for
PERMITS BECOME VOID IF WORK OR CONSTRUCTION AUTHORIZED IS Plan Review if reauired (Sec.3) $
NOT COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK Subtotal C,( $
IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY (J
TIME AFTER WORK IS COMMENCED. ❑ Trust Account # 0p2
Total balance Due $
I: \DSTS \ELC96.APP Rev 9/96
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RECEIVED
NOV 071997
COMMUNITY DEVELOPMENT