Permit e h_l_v_k ,___, 0 6,._ q c
Community Development ELECTRICAL PERMIT APPLICATION
Tigard, OR 97223 Permit # L C_ � (� -C'�/ c
'^'' 13125 SW Hall Blvd.
�r* 1, '1` Date Issued C
el II Phone (503) 639 -4171 E.
FAX (503) 684-7297 10 .._;6c-,(6, CITY OF TIGARD
TDD No. (503) 684- 27/2-U/0c
Inspection (503) 639 -417
1. Job Address: 4. Complete Schedule Below:
Name of Development / K' Number of Inspections per permit allowed
Address / �1 L/} .�ti,/ 77_ i ", /a 1.,c Service includ d :\ /
' Items Cost(ea) Sum •
City /State /Zip /.4 ,..,-, -, i 1 . 7 4 a . � t s ldential ` k �p r unit
\ 1000 s ft for less' V $110.00 4
Name (or name of business) ,)ice i,, >? C I 'L \ Each adgdional 500 sq. ft. or
( portion thereof $p5.00
Commercial LJ Residential ❑ Limited Energy $28.00 1
' Each Manurd Home or Modular
' Dwelling Service or Feeder $68.00 2
2a. Contractor installation only:
4b. Services or Feeders 2
Electrical Contractor l amps or Less on, or relocation $60.00 7OO
2
Address \\
A 1 201 amps to 400 amps $80.00 C CC 2
401 amps to 600 amps $120.00 2
City State Zip 601 amps to 1000 amps : $180.00 alit) 2
Phone No. Over 1000 amps or volts $340.00 2
Job NO. Reconnect only
$50.00 2
contractor's license NO. ' '4c. Temporary Services or Feeders
Contractor's Board Reg. No. Iv Installation, alteration, or relocation
Signature of Supr. Elec'n / 200 amps or less 2
License No. Phone No. 201 am to 400 amps $80.00 2
401 amps to 600 amps $
Over 600 amps to 1000 volts $100.00
2b. For owner installations: see "b" above.
4d. Branch Circuits
Print Owner's Name New, alteration or extension per pane
Address a) The fee for branch circuits with
purchase of service or feeder lee. 2
City State Zip Each branch circuit 16. $5.00 9
Phone No. b) The fee for branch circuits without
The installation is being made on property I own which is purchase of service or feeder fee. 2
not intended for sale, lease or rent. Flat branch circuit $35.00
Each additional branch circuit 35.00
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or irrigation circle $40.00 2
Each sign or outline lighting $40.00
Signal circuit(s) or a limited energy 2
Please check appropriate item and enter fee in section 5B. panel, alteration or extension 5- $40.00 ZOO
4 or more residential units in one structure Minor Labels (10) $100.00
-K Service and feeder 225 amps or more
System over 600 volts nominal 4f. Each additional inspection over
Classified area or structure containing special occupancy the allowable in any of the above
as described in N.E.C. Chapter 5 Per inspection $35.00
Per hour $55.00
In Plant $55.00
Submit 2 sets of plans with application where any of the above
apply. Not required for temporary construction services. 5. Fees:
5a. Enter total of above fees $ J2OL°°
NOTICE 5% Surcharge (.05 X total fees) $ ` gyp •00
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5b. Enter of line A for
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Reevivi of
if required (Sec.3) $ 14'60
A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal $
COMMENCED. wardlwmdeNeko ❑ Trust Account #
$ �,
prm.app
Balance Due $ Z� 4 962 c° �)
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