Permit Electrical Permit Application !' r ` . _ !! 1."0 It OFFICI.: USE ONLY
gni City of Tigard Received Permit No.: �� • ` 11* 131 lvd.,Tigard,OR 97223 JUN 1 2009
Phone: 503.639.4171 Fax: 503.598.1960 Pla 12 Trim lim Other Permit:
ille Inspection Line: 503.639.4175 CITY OF TIGA RD Date Rea' `By: w ISIO runs: See Page 2 for
Internet: www.tigard - or.gov [RANG DIVISIO Notified/Method: / , � r� � ' ® Supplemental Information
TYPE OF WORK l� 6JI V 7 V PLAN REVIEW
❑ New construction ❑ Addition/alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ 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 ❑ 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 ", "I -3 ",
Job no.: I Job site address: 7 C' 5� gi* Q Al //4 .n 100HP or more. occupancy.
f 0 Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: / y 4 (,J 9 7123 ❑ Health -care facilities.
0 Supply voltage for more than
G ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: fk C 24 ,4 ige Service or feeder 600 amps or more.
� / FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. 1 Fee. 1 Total 1 •
1^ New residential single- or multi - family dwelling unit.
V h i C .Y l e ICn nej) Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family 75.00 2
3 Ao $ 7 G JQc 01 jlt o 11a�x> residential (with above sq. ft.)
/� Services or feeders installation, alteration, and/or relocation
p /,,< r 4 . 0 r" Z f a .1! . pJKf s V< 200 amps or less 80.30 2
❑ P OPER Y 0 NER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: c # 1/ 1—/ 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: 3 / 24. 5-- 5 pi, ilve...4 Over 1,000 amps or volts 454.65 2
City/State /ZIP: 7774e/Led p {Z-- .7 7 2 Temporary services or feeders installation, alteration, and/or
relocation
Phone: (5'3) G 47.- 4//7 / 1 Fax: ( ) 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 599 amps 133.75 2
Branch circuits — new, alteration, or extension, per panel
Owner signature: _ Date: A. Fee for branch circuits with
❑ APPLICANT I ['CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit
Business name: B. Fee for branch circuits
/ , J without service or feeder fee, t
Contact name: 46.85 2
N A.J S first branch circuit
Address: g 7 7 'PO Lie Each add'I branch circuit �p 6.65 2
7 Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
dwelling, service and/or feeder 90.90 2 •
Phone: ( ) Fax: ( ) Reconnect only 66.85 2
E -mail: /V Z4,0 7'/p4 QQ,2d t! Pump or irrigation circle 53.40 2
1 CONTRACTOR Sign or outline lighting 53.40 2
Business name: F Signal circuit(s) or limited -
energy panel, alteration, or
Address: extension. Describe: Page 2 2
City/State /ZIP: Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50
CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
Print name: Date: Plan review (25% of permit fee):
State surcharge (12% of permit fee):
Authorized signature: TOTAL PERMIT FEE: 7 1 t
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete,
/� C ‘,200-9, a S' /� 2 • Number of inspections allowed per permit. n ( J Y
I:\ Building \Pennits\ELC- PermitApp.doc 05/23/06 G ‘ ,2 00 - 9 , 440-46 T l l /05 /COM/WEB f V
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
p 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 03/23/06