Permit n CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
1 111 1 °..: .- COMMUNITY DEVELOPMENT Permit #: ELR2010 -00214
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/12/2010
Parcel: 2S109DA18100
Jurisdiction: TIGARD
Site address: 15209 SW SUMMERVIEW DR
Subdivision: ARLINGTON HEIGHTS NO. 3 Lot: 110
Project: Arlington Heights No. 3, Lot 110
Project Description: (1) vacuum system
FEES
Owner.
STONE BRIDGE HOMES Description Date Amount
16869 SW 65TH AVENUE #505 Restricted Energy Permit 10/12/2010 $75.00
LAKE OSWEGO, OR 97035 12% State Surcharge - Electrical 10/12/2010 $9.00
PHONE: 503 - 387 -7577
Contractor:
A -1 SERVICE INSULATION LLC
PO BOX 3941
HILLSBORO, OR 97123
PHONE: 503 - 984 -9542
FAX:
Type of Use: SF
Class of Work: NEW
Total Number of Systems:
•
Audio & Stereo: N
Security Alarm: N
Garage Door Opener: N
HVAC: N Total $84.00
Vacuum System: Y
Required Items and Reports (Conditions)
Other N
Other Desc:
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 6 : Permittee Signature: �/ /// /
Y ,A
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 603.639.4176 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 protect
Approved plans are required on the job site at the time of each Inspection.
Electrical Permit Application FOK 01:1:1C1.1 usl: ONLY
�1 V
T eceived
City of Tigard REC .G : /0 /L /o �; Permit +"'" /O — 00•?/
13125 SW Hall Blvd., Tigard, OR 97223 - .� V I:r. an Review , 2a
11 Phone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit/yj�� /0 .- / 40 / s�
.1 1 t A it 1 Inspection Line: 503.639.417 0 C T 1 Date Ready/By: ® Page 2 for
Internet: www.tigard or.gov / Notified/Method: Iffn Supplemental Information
TYPE OF WORK CITY OF TIGARD PLAN REVIEW
❑ New construction a Addition/alteration ikEMI J DIVISION Please check all that apply (submit 2 sets of plans w /items checked below):
I ❑ Service or feeder 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
1 and 2 family dwelling ❑ Commercial/industrial El 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 ", "I - ", "I - ",
le address: �/�7 �y �o� 100HP or more. occupancy.
Job no.: Job
' I1G - /��f/ ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: ....A.r "( ❑ Health -care facilities. ❑ Supply voltage for more than /
/ / ❑ Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description 1 Qtr. 1 Fee. 1 Total 1 •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family
residential (with above sq. ft.) 75.00 2
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
PROPERTY OWN I ❑ TENANT 201 amps to 400 amps 133.56 2
h t ' �,I� C 401 amps to 600 amps 200.34 2
Name: 6 l VlY D / /� /hi ps P
601 am to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Ci /State /ZIP: Temporary services or feeders installation, alteration, and/or
h relocation
Phone: ( )
Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange, 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: Date: A. Fee for branch circuits with
❑ APPLICANT 1 ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
h 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: C yr (/ � a c �j ,�/ panel, alteration, or extension. Page 2 2
-/ � v ff _A..45 /'�i / i l/� Each additional inspection over al owable in any of the above
Address: rp , 7G� /� Additional inspection (I hr min) 6625/ hr
City/State /ZIP: / /� e9. 77/2_3 Additional
(1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: (7'23) ��� Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed ( hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signatu tired: o Subtotal: ? S .
Plan review (25 /o of permit fee):
Print name: Date: State surcharge (12% of permit fee): % ,
� TOTAL PERMIT FEE: ail/, cr
Authorized signature: >� I � % / This permit application expires if a permit is not obtained within 180
- ,( Print name: 64,Z ( 5 Date: �� /a 7&
days Li it has been accepted as complete.
J , / � - ' • Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 07/01/10 440-4615T(11/05 /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*
1 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