Permit q CITY OF TIGARD ELECTRICAL PERMIT
' "1 COMMUNITY DEVELOPMENT Permit #: ELC2010 -00708
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/22/2010
Parcel: 1S133AD12000
Jurisdiction: Tigard
Site address: 11285 SW SUMMER LAKE DR
Project: DEXHEIMER Subdivision: SUMMER LAKE Lot: 1
Project Description: (3) branch circuits for NC, outdoor outlet, and to reconnect furnace.
Contractor: SIMPLY SHOCKING LLC Owner: DEXHEIMER, SHERRY E
15118 S WOODGLEN WAY 11285 SW SUMMER LAKE DR
OREGON CITY, OR 97045 TIGARD, OR 97223
PHONE: 503 - 880 -8649
PHONE: 503 - 313 -3980
FAX:
FEES
Quantity Description Date Amount
3 crt Branch Circuits wo /Purchase 12/22/2010 $71.02
Specifics: Service or Feeder
1 ea 12% State Surcharge - 12/22/2010 $8.52
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $79.54
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. 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 r,i -s adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy • . or.direct questions to OUNC by calling 503.232.1987 or 1.8 32.2344.
Issued B �� /� — �� Permittee Signature:
41/201P
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 • FOR OFFICE USE ONLY
CI of Ti and ® Received n.,/ _ permit No.:
ill `.1 g DateB : I 4'p ( , • to.— -7 U,
13125. SW Hall Blvd., Tigard, at" v ° ` Plan Review
4 Phone: 503.639.4171 Fax: 50 t , � I Other Permit:
. q � r� Date/B
I I c A K D Inspection Line: 503.639.4175 P Date Ready/By: ® See Page 2 for
Internet: www.tigard or.gov SE C I Notified/Method: Supplemental Information
TYPE OF WOI�tt O . t o ` \ , PLAN REVIEW
❑ New construction Addition/alterat \`\ Ifnent Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Demolition ❑Other: v
Q 12 Service or feeder 400 amps or more ❑ Building over three stories.
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
t- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑Multi- family 0 Master builder 0 Other: 0 Fire pump. ❑ Installation of75KVAor,, -
JOB SITE INFORMATION AND LOCATION ❑ Emergency system- larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "l -3 ",
Job no.: Job site address: // Ze -- s� 5c,,,,,,,,.... or more. occupancy.
❑ Six Six o or r more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: ID Health- care.facilities. ❑ Supply voltage for more than
/ t �j _❑ Hazardous locations. 600 volts nominal.
• (� ❑ Service or feeder 600 amps or more.
Suite/bldg. /apt- no.: Project name: /�� _ �e� � FEE SCHEDULE
Cross street/directions to job site: - '�C.JC Description [ Qty. I Fee. : I Totae I •
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'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
�/ /� Limited energy, multi - family
,1 . Ri foAGL. Z 1.O ,t h `4- D (ii-040r o f residential (with above sq. ft.) 75.00 2
/ Services or feeders installation, alteration, and/or relocation
• 200 amps or less 100.70 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 • 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
tY 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 401 amps to 599 amps 168.54 2
. . intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. -
Branch circuits — new, alteration, or extension, . er panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑ 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'l branch circuit 2 7.42 2
Address: Miscellaneous (service or feeder not included)
Ci /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:
Signor outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
/ i - panel, alteration, or extension. Page 2 2
Business name:
/wp SIM , f\ Each additional inspection over allowable in any of the above
Address: v Additional inspection (1 hr min) 66.25/ hr
,� 70 tI� Investigation (1 hr min) 66.25/ hr
City/State /ZIP:
d,/, 4ri1 ter'/ o 7 Industrial plant (1 hr min) 78.18 / hr
Phone: V 1 ' � Fax: Inspections for which no fee is
( ' y 3 7 ( ) specifically listed (Vs hr min) 90.00 / hr
CCB Lie.: ! f ( 1 Electrical Lie.: c ,-� 7 Suprv. Lie.: 3 s 5 3 S ELECTRICAL PERMIT FEES
Suprv. Electrician signature, requ / Subtotal:
_� /` v / Plan review (25% of permit fee):
Print name: . 7 -- /- - - - vC 4 , e e g I Date: /., 2/.._ / a State surcharge (12% of permit fee): 3 q_
TOTAL PERMIT FEE: 1. S
Authorized signature: T his p ermit application expires if a per is not obtained within 180
Print name: D ate: j _ q days after it has been accepted as complete.
� 5 �� k
- ZG " 1O • 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*
❑ 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
n Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
n Instrumentation
n Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
d
Outoor Landscape Lighting*
❑ 1' g g*
❑ Protective Signaling
Fl Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
IABuilding \Pennits\ELC- PermitApp.doc 07/01/10