Permit CITY OF TIGARD ELECTRICAL PERMIT
11 11- C OMMUNITY DEVELOPMENT P ermit #: ELC2011 -00102
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/22(2011
Parcel: 2S 110DD03300
Jurisdiction: Tigard
Site address: 10490 SW CENTURY OAK DR
Project: Stensrud Subdivision: SUMMERFIELD NO. 1 Lot: 40
Project Description: (1) branch circuit to re- connect gas furnace.
Contractor: BEN'S HEATING & AIR CONDITIONING LLC Owner: STENSRUD, KATHRYN R
PO BOX 80607 10490 SW CENTURY OAK DR
PORTLAND, OR 97280 TIGARD, OR 97224
PHONE: 503 - 245 -7563
HONE: 503 - 233 -1779
FAX: 503 - 651 -3345
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 02/22/2011 $56.18
Specifics: Service or Feeder
1 ea 12% State Surcharge - 02/22/2011 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OA 01 -0090. You may 'r . • • •f the 'r direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: - _� Permittee Signature:
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 . Volt of l it t: l•St': ONLY
City of Tigard Received ��
OZ o �1 / /. ' /I Permit No - DQ�O e2-
711 • 13125 SW W Hall Blvd., Tigard, OR 97223 Plan Ravle
Phone: 503,639.4171 Fax: 503,598.1960 Date/13 ; Other Permiy���„Zp�� p
I I i.i A It l 1 Inspection Line: 503.639.4175 Date Ready /ay; lurir Sit See Page 2 for
Internet; www,tigard- or.gov Notified/Method; -- • Supplementallnfarwntiun
TYPE OF WORK PLAN REVIEW ,
❑ New construction cgl Addition/alteration /replacement Please cheek all that apply (submit Z. sets of plans w /items checked below)
El Service or feeder 400 amps or more Cl 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 -one egriculturaI
54 1 - and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
0 Multi - family ❑ Master builder [] Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ` El Addition of new motor load of D "A ". "E ", "1.2 ", "1-3",
fn I /02 /'t pw' r� , , A V A^ sic or more, occupancy
Job no.: Job site address f (f 7 ( rc-1 V (f
❑ Six or more e R residential units. ❑ Recreational vehicle pm ks.
City/State/ZIP: ,, / * Cl Health -Dare facilities. I=1 Supply voltage for more than
�' - ar ❑ Hazardous locations, 600 volts nominal
Suile/bldg, /apt. no.: Project name: ❑ service or feeder 600 amps or more. _
• FEE SCHEDULE
Cross Street/directions to Job site: Description - I Qty. I Mss. I 'fetal I -
New residential single- or multi- family dwelling unit.
Includes attached gara
Subdivision: Lot no.: 1.000 sq. ft. or less 168.54 4
Tax ma P /steel no.: Ea. add'l 500 sq. ft. or portion 33.92 1
P — Limited energy, residential
, ' y ' s 67 2
DESCRIPTION OF WORK , ..r , • ( with above S ft .. )
y
,/� Limited energy, multi- family 67.84 2
K e rCn '( j 'F C� C&' j
( / residential (with above sq. fl.)
.f! Services or feeders installation, alteration, and/or relocation
200 amps or less _ 100.70 2
PROPERTY O,i ER - ❑ TENANT' 201 amps to 400 amps 133,56 2
` ■ e - 401 amps to 600 amps 200.34 2
Name A � L ■ ed 601 amps to 1,000 amps 301.04 _ 2
' tddress: 1 'EMS L - J , 1 r �, 4 Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, a nd /or
ity /State /Z1P: F L ` 4 V relocation _
Phone:,(' ) a F L ..- Fax: ( ) 200 amps or less 59.36 _ _ 1
201 amps to 4(x1 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
above service or feeder fee,
a , APPLICANT • Ci CONTACT PERSON 7.42 each branch circuit
name: B. Fee for branch circuits without .. f 2
u�G service or feeder fl e, first (/ 56.18 ,/f?
l__ I
Contact name: !�'""� LA N branch circuit
1 Each add'I branch circuit 7,42 2
Address: Miscellaneous (service or feeder not included) _--- mm _ _
City /State /ZIP —! Each manufactured or modular 67 84
dwelling, service and/or feeder
Phone: (-03) 3 13 - q Reconnect only 67.84 2
NO ' Fax; : ( ) y
--- Pump or irrigation circle 67.84 2
E -mail: _ Sign or outline lighting 67.84 2
CONTRACTOR , Signal circuit(-) or limited- energy
• Business name: c tt A. panel, alteration, or extension. Page 2 2
E ach additional inspection over allowable in a ny o f the above
Address: I_ Q (3Q) g o & 1 t Additional inspection (I hr min) 66.25/ hr
City/State /ZIP: , Q �1 l t lr'N� Der ! - ass Investigation (I hr min) 66,25/ hr
I Industrial plant (I hr min) 78.18 / hr
61711e: 4-1.s } �,�1 Fax:) 6-5/ Inspections for which na fee is 90.00/ hr
W / El ectrical Lic.: p ,1 Suprv. L,iC.: specifically listed (15 hr min)
H Llc.:
b� y / ? p 7 7 ELECTRICAL PERMIT FEES
� �� _ I Subtotal: 1 ..5 r /ef
Suprv. Electrician signature, required:
- Plan review (25% otpermit fee):
- rrint name: I 40 ' 3 1) r• . ,ti Date: , t, / i State surcharge (12% of permit fee): ‘ 7 y _
��_ gn �rt TOTAL PERMIT PEE:
Authorized signature: This p erm i t a expires if a permit le not obtained within ISO
Print name: Date: days after it has been accepted as Complete.
s� Y �(� Number u1' inspections allowed per permit.
I1 BuddtngtPe rmits\ELC PermitApp 10/01/09 440 -461ST(I11031C /WEB
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