Permit 1,1 CITY OF TIGARD ELECTRICAL PERMIT
2 ' , '- COMMUNITY DEVELOPMENT Permit #: ELC2010 -00652
13125 S Hall B lvd., T igard OR 97223 503.718.2439 Date Issued: 11/17/2010
• T1C , . Parcel: 2S103CB04903
Jurisdiction: Tigard
Site address: 13613 SW 121ST AVE
Project: Subdivision: Lot: 0
Project Description: Electrical reconnect
Contractor: Owner: BELMONT INVESTMENT PROPERTIES LL
24515 SW MOUNTAIN RD
WEST LINN, OR 97068
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Reconnect Only 11/17/2010 $67.84
Specifics:
1 ea 12% State Surcharge - 11/17/2010 $8.14
Electrical
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $75.98
Required Items and Reports (Conditions)
This perm is'igsued s• •.- t to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be do in accordance with a• •roved • ans. 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 r= •uire. • u to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in
95 001 -0010 through OAR 952 -00 do 1090. ay obtain a a(/ cop py y of the rules or direct questions to OUNC by calling 503.232.1987 0 .800.332.2344.
I sued By: Ls. 4 � i Permittee Signature: k
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 503.639.4175 by 7:00 a.m. for the next available inspection date.
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 Application F O FFICE USE ONLY
C of Tiga Date/13 : l/ /c /6 PermitNo.: & 65- ° 13125 S W Hall Bl vd., Ti OR 97 223 Plan Review
11 4
• 13 ..- P hone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit:
1' l G A R D Inspection Line: 503.639.4175 Date Ready/By: lu rt : 10 See Page 2 for
Internet: www.tigard - or.gov Notified/Method: / (6,. Supplemental Information
TYPE OF WORK 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
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2", "I -3",
Job no.: Job site address: 100HP or more. occupancy.
/3(a �(.v / 21 �� ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: --^ �Q 6/720 ? ❑ Health -care facilities. ❑ Supply voltage for more than
1 /G J ✓� J ❑Hzardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name:,' / /( ❑ Service or feeder 600 amps or more.
✓✓VV FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. 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 75.00 2
-,, I 1 l t ' �∎ A Q. �� residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
. 200 amps or less 100.70 2
❑ 'PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: �ckV' C '�, -on � 601 amps to 1,000 amps 301.04 2
Address: kr `'� St--At 126 _ Over 1,000 amps or volts 552.26 2
, Temporary services or feeders installation, alteration, and /or
Ti City /State /ZIP: I e A c /� c' 7 Z Z.3 relocation
Phone: ( q '2) 4 g - 3360 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 ❑ 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)
Each manufactured or modular
City /State /ZIP: 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 7 67.84 4 „9tL 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: panel, alteration, or extension. Page 2 2
Each additional ins over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) 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 signature, required: o Subtotal 7, ��
Plan review (25% of permit fee): ....
Print name: Date: State surcharge (12% of permit fee): 3,1 q
TOTAL PERMIT FEE: 76; n
Authorized signat e: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: /f u Date: r ( / / 0 * Number of inspections allowed per permit.
B P \ E
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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:
n Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
n Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
n Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
n Instrumentation
n Intercom and Paging Systems
Fl Landscape Irrigation Control*
n Medical
n Nurse Calls
n Outdoor Landscape Lighting*
n Protective Signaling
n Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
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