Permit CITY OF TIGARD ELECTRICAL PERMIT
PERMIT #: ELC2005 -00773
�� DEVELOPMENT SERVICES DATE ISSUED: 10/12/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 - 4171
PARCEL: 1 S136A6 -01800
SITE ADDRESS: 10296 SW 72ND AVE ZONING: R -4.5
SUBDIVISION: METZGER ACRE TRACTS LOT : 004 JURISDICTION: TIG
Project Description: 1 circuit for HVAC
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL/PANEL:
MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: >=4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
ROGER/SUSAN WORF WASHOUGAL ELECTRIC & SHEET METAL
14861 SWCITRINE LOOP 4702 NE 199TH ST.
BEAVERTON, OR 97007 RIDGEFIELD, WA 98642
Phone: 503 - 524 -4790 Phone: 360 - 571 -2277
FEES Reg #: ELE 37 -1047C
LIC 161564
Description Date Amount SUP 4276S
[ELPRMT] ELC Permit 10/12/200' $46.85
[TAX] 8% State Surcharge 10/12/200' $3.75 REQUIRED ITEMS AND REPORTS
Total $50.60
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 through OAR 952 - 001 -0100. You may obtain copies of these rules or di ect questions to OUNC at
503 - 246 -6699 or g7 l
Issued By: � /�� Permittee Signature: p,� 1/0
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:
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 Ar '�'VED FOR 01:V ICE 1: u51: c,� i
City of Tigard V p � ( ,� / I a /o 5 /5 Permit No.: 0 ��06 - 77
13125 SW Hall Blvd., Tigard, OR 972 Plan Review
Phone: 503.639.4171 Fax: 503.598. 12 2005 ' "'p +' i'' Date/By OtherPennit:
Inspection Line: 503.639.4175 0, ' � Date Ready/By. 1 •' : ® See Page 2 for
Internet: www.ci.tigard.or.us CITY OF TIGARD Notified/Method iei Supplemental Information
BUtk® DNIII DN PLAN(SEVIEW
❑ New construction ddition/alteration/replacement Please check all that apply:
❑ Demolition ❑Other: ❑Service over 225 amps, comm'l ['Hazardous location
❑Service over 320 amps — rating ❑ Buildng over 10,000 sq. ft.,
CATEGORY OF CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential
— 434, - and 2 family dwelling ❑ Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi - family ❑Master builder ❑Other: ❑Building over three stories ['Feeders, 400 amps or more
['Occupant load over 99 persons ❑Manufactured structures or
JOB SITE INFORMATION AND LOCATION gh g plan RV park
❑Egrt:ss/li tun Ian
Job no.: Job site address: /Q�G9‘ 560 7z ❑Health care facility ❑der
Submit 2 sets of plans with any of the above.
City/State/ZIP:� #1� ,� construction 3 The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name: FEE* SCHEDULE
Description I Qty. 1 Fa. I Taal
Cross street/directions to J ob site: �'42'P-'x��1 ' ) Q New residential single or multi family dwelling unit.
` ` / f' Includes attached garage.
/d /o N,/ 1,000 sq. ft. or Tess 145.15 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft or portion 33.40 1
Limited energy, residential 75.00 2
Tax map /parcel no.: /.S /3ao .C6' /3 /860 Limited energy, non-residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
���, �' � �/✓ dwelling, service and/or feeder 90.90 2
���1 � //' -1 -/rd �1l' -a- 77 /� /� -Cf-ue r Services or feeders installation, alteration, and/or relocation
Z 200 amps or less 80.30 2
kKBROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: ' — i Gr' ' �n , Z.Z.Ab. 601 amps to 1,000 amps 240.60 2
i
Address: /,5//q4 l C(A) e 5��x . y / Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/ State/ZIP:` 4.t t/Ft�-ic_.)A1 & i._.. 1 Temporary services or feeders installation, alteration, and/or
Phone: ) /9 I Fax: (� �'T3) �b 29 9 relocation
�� y7 D 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 • 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 2
Owner signature: Date: Branch circuits — new, alteration, or extension, per panel
❑ APPLICANT 1 ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
Address: each branch circuit '
Each add'I branch circuit 6.65 2
City/ State/ZIP: Miscellaneous (service or feeder not included)
Phone: ( ) Fax:: ( ) Pump or irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E - mail: Signal circuit(s) or limited -
CONTRACTOR energy panel, alteration, or
/6 �� / � ' 04 extension. Describe: Page 2 2
Business name: � �,.��w1����7�� c i "
Address: A / ' G79� , Each additional inspection over allowable in any of the above
7 Per inspection 62.50
City/State/ZIP: �� �7 a >� • 996 [/L Investigation per hour (I hr min) 62.50
Phone: (( S7/ „ // -7 7 Fax: (' ,c ) s —676/ Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES*
CCB Lic.: J) /,t Electrical Lic.: 37 /697pSuprv. Lic.: e :s 'o :
7S Subtotal /f -
Su p rv. Electrici I adsi '' re, aired: "7 — / — 6 7 0 /0/i0 7 Plan review (25% of permit fee)
Date: / State surcharge (8% of permit fee) 3 .74
Print name:
��TNONr �Qv /6 � TOTAL PERMIT FEE - to
Authorized signature: /// This permit application expires if a permit is not obtained within 180
- days after it has been accepted as complete
Print name: Date: • Fee methodology set by Tri- County Building Industry Service Board
• • Number of inspections per permit allowed
i:\ Building \Pennits\ELC- PennitApp.doc 12/03 440.4615T(10/02/COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: —1
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
El Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
C COMMERCIAL WORK ONLY: -- —
Fee for each commercial system. $75.00
(SEE OAR 918- 260 -260)
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
i:' Building \Pennits\ELC- PemitApp.doc 04/03
CITY OF TIGARD ���
13125 S.W. HALL BLVD. E1 �
TIGARD, OR 97223 I �/
IMPORTANT PERMIT NOTICE • OCT 13 1005
CITY OF
Ma]) TIG ARD.
WASHOUGAL O 199TH ELECTRIC & SHEET METAL U G DM
% N
RIDGEFIELD, WA 98642
`AX - 34 - 57/- 5/(0/
Electrical Signature Form
.P_ermit. .. LC2005 _
Date _ — _ _ . _ - - - - - - .
Parcel: 15136AB -01800
Site Address: 10296 SW 72ND AVE
Subdivision: METZGER ACRE TRACTS
Block: Lot: 004
Jurisdiction: TIG
Zoning: R-4.5
Remarks: 1 circuit for HVAC
Your company has been indicated as the electrical contractor for the permit indicated above. In order for
the electrical permit to be valid, the signature of the supervising eledrician is required. Please have the
appropriate individual from your company sign below and return this Electrical Signature Form prior to the
start of the work to the address above, ATTN: Building Division.
No electrical inspections will be authorized until this completed form is received
OWNER: ELECTRICAL CONTRACTOR:
ROGER/SUSAN WORF WASHOUGAL ELECTRIC & SHEET ME i
14861 SW CITRINE LOOP 4702 NE 199TH ST.
BEAVERTON, OR 97007 RIDGEFIELD, WA 98642
Phone #: 503 -524 -4790 Phone #: 360.571 -2277
Reg #: ELE 37 -1047C
1..1C 161564
SUP 4276S
AN INK SIGNATURE IS REQUIRED ON THIS FORM
X
Signature of Supervi ing Electrician
If you have any questions, please call 503.718.2433.
•d
J
CITY - -,OF TIGARD - _,^
,
BUILDING DIVISION PERMIT #: ELC2005-00773
13125 SW Hall Blvd., Tigard, OR 97223 D ATE ISSUED: 10/12/2005
Phone: (503) 639 -4171 pAbili i,
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 10/21/2005 TIME: 7:08AM PAGE: 36
SITE ADDRESS: 10296 SW 72ND AVE CLASS OF WORK:
SUBDIVISION: METZGER ACRE TRACTS LOT #: 004 TYPE OF USE:
PROJECT NAME: WORF
DESCRIPTION: 1 circuit for HVAC
OWNER: WORF, ROGER /SUSAN PHONE #: 503- 524 -4790
CONTRACTOR: WASHOUGAL ELECTRIC & SHEET METAL PHONE #: 360 -571 -2277
Inspection Request Scheduled For: Date: 10/21/2005 Pour Time:
Code # Inspecti • • • - • • ion Confirm # Contact # Message
195 isc. inspecti t - e 019003-01 503 -784 -8497 N
Corrections /Comments /Instructions: C i� /■C- �, Nr..Q. e4 C2
Ree...ANEA F ;tool- airovsl. .
Tho elootricol installation defects noted
on this report shall be corrected and
an inspection request made within 90
calendar days per OAR 918 -271 -0030
EXPIRED
ELe el miCAL (D100
*I s N D Lon%c i ti
l 3vS6iNd56 . UU RI-06
Cri.r.lbal'
PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: ) 0 — Z- I' D � Phone #: (503) 718-
_______/:MLEA_____