Permit CITY OF TIGARD ELECTRICAL PERMIT
6 ,+
lc COMMUNITY DEVELOPMENT Permit #: ELC2010 00696
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/16/2010
Parcel: 2S110BA03200
Jurisdiction: Tigard
Site address: 11515 SW CLOUD CT
Project: SORENSEN Subdivision: SHADOW HILLS Lot: 32
Project Description: Removing and replacing electrical panel.
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Contractor: OWNER Owner: SORENSEN, ALLEN C & CATHIE A
11515 SW CLOUD CT
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES •
Quantity Description Date Amount
1 ea Services or Feeders - 200 12/16/2010 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 12/16/2010 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. At work wit
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 ru - are set forth in OAR
952- 001 -0010 through a 952- 001 -0090. Y. ay obtain a copy oft ect questions to OUNC by calling 503. I or 1.800.332.2. • •.
Issued By: 952-001-0090.
r._..... .� Permittee Signature: LPL ilj.��
i i,� /
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.
Cali 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 OR OFFICE> USE ONLY
III . i .
City of Tigard DateB 1, HAWN Permit No — Cr
° 13125 SW Hall Blvd., Tigazd 3
I Plan Review \\ O
C Phone: 503.718.2439 Fax: c ; 960 '' r�0'�Q DateB : Other Permit: T I G A R D Inspection Line: 503.639.417 6 1- Date Ready/By: EMI ® See Page 2 for
Internet: www.tigard - or.gov o n o Notified/Method: Supplemental Information
TYPE OF WO ® � \O PLAN REVIEW
ti ,.,ills
❑ New construction ,� Addition/altet(erk 7� ` nt
Please check all that apply (submit 2 sets of plans w /items checked below):
�t�q � e�lac�me
r ❑ Service or feeder 400 amps or more ❑ Building over three stories.
1=1 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
0 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 ", "1 -3 ",
Job no.: Job site address: 100HP or more. occupancy.
1 �/� 50 - '( ru �` (,� ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: / 6
G� 2 Y ❑ Health -care facilities. ❑ Supply voltage for more than
/ l / ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: Sd re NS ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description 1 Qry. 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 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
A Limited energy, multi- family 75.00 2
nA �..e— .* i� (( �, Elcct 16&,��L residential (with above sq. 11)
��` I /' Services or feeders installation, alteration, and/or relocation
200 amps or Tess ' 100.70 1 &1, 7J 2
PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
So `� "rM " S� 401 amps to 600 amps 200.34 2
Name: f / 1 601 amps to 1,000 amps 301.04 2
Address: I '5l 5 S Lu E cr Over 1,000 amps or volts 552.26 2
City/State /ZIP:
/ 6/ City/State/ZIP: (J l Ct r ( ,22 Temporary services or feeders installation, alteration, and /or
/� rK relocation
Phone: (50 ) '3R.- 85011 Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This i to 1., ion is being AO e on property that I own which is not
intended for sale, lease, ri,,d/if change, aces rn to ORS 447, 449, 670 , an 701 1
401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, per panel
Owner signature: r` i 'if ' 4 ' i ate: / 1 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)
City/State/ZIP: /State /ZIP: Each manufactured or modular 67.84 2
ty 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: panel, alteration, or extension. Page 2 2
Each additional inspection 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 (/2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: 106 .*-1 c7
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): l , 0 S(
TOTAL PERMIT FEE: ( -
Authorized signature: This permit application expires if a permit is not obtained within 180
7/ld � D /� //b / io • d spe after a has d been accepted as complete.
Print name: / � Number of inspections a llowed per permit.
I:\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:
n Audio and Stereo Systems*
❑ Burglar Alarm
n Garage Door Opener*
n 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:
n Audio and Stereo Systems
n Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
❑ Other
Total number of commercial systems:
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*No licenses are required. Licenses are required
for all other installations
I: \Building\Permits\ELC- PermitApp.doc 07/01/10
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with he Construction Contractors Board.
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will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
1 have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and 1 hereby certify that the information on this homeowner statement is true and accurate.
fii/a. v11 --/U te 1J5!i/k
Print Name of PermitAppli
Atezo AO (0
Signature of Permit Applicant Date
Permit #: -CX(O &q
Address: 1 SL CIO-Lei CI • �� .%
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Issued by: 8.1 - Date: /2//6
This Copy for Permit Offices