Permit CITY OF TIGARD ELECTRICAL PERMIT
III 2 COMMUNITY DEVELOPMENT Permit #: ELC2011 -00130
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/10/2011
Parcel: 2S112BD01700
Jurisdiction: Tigard
Site address: 15050 SW 79TH AVE
Project: CARLSON Subdivision: DURHAM ACRES Lot: 38
Project Description: (1) branch circuit for sewage pump.
Contractor: OWNER Owner: CARLSON, BRUCE & VICKI
15050 SW 79TH AVE
TIGARD, OR 97224
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 03/10/2011 $56.18
Specifics: Service or Feeder
1 ea 12% State Surcharge - 03/10/2011 $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 throu• • = .'52- 001 -0090. You may o• -'• - • • • • -ct questions to OUNC by calling 503.23 87 or 1.800.3 .2344.
Issued By: ` .- -.__, Permittee Signature:
OWNER INSTALLATION ONLY
7
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 Fo12 OFFICE t SE ONl.\
City of Tigard j � Dateived /
y Permit No.:
a 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
_ . } 1 _`
Phone: 503.718.2439 Fax: 503.598.1960 (['`�� .\ Date/By: Permit: ,/�,,i
y: r' 7�Jj)— e.Y�
T I GARD Inspection Line: 503.639.4175 N.) 'l� Date Ready /By: luris: H See Page 2 for
Internet www tigard or gov 1% c) ytified/Method: Supplemental Information
f E , q ' w® 1i ELAN RJ REVIEW
i on/replacovtp04 1 ,(� � ° Please check all that apply (submit 2 sets of plans w / items checked below):
Li New construction ® Addition /alterat
; ❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑Other. �:. ,.'\,)\-. where the available fault current ❑ Marinas and boatyards.
emiGOR's' OF CON R1 e a 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.
JO ITE I1 1 AND N LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ",
100HP or more. occupancy.
Job no.: Job site address: 15050 sw 79 ave
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: Tigard, OR 97224 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
F'II Z :St/MU
Cross street/directions to job site: 79 south of Bonita Description I Qtr. I Fee. I Total 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' 1 500 sq. ft. or portion 33.92 I
Tax map /parcel no.: 2S 1 12BD Limited energy, residential
It.) 75.00 2
= '; . D)H;SC1I1�1`TION OF WORif' ( with above sq.
Limited energy, multi - family 75.00 2
Install new circuit for sewage residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
ejector pump 200 amps or less 100.70 2
0 PROP) 'RTV OWNII R . 0 TENANT 201 amps to 400 amps 133.56 2
" ' 401 amps to 600 amps 200.34 2
Name: Bruce Carlson 601 amps to 1,000 amps 301.04 2
Address: 15050 sw 79 ave Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City/State /ZIP: Tigard, OR 97224 relocation
Phone: (503)6241133 Fax: (503)6240903 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This i i tallation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease; t, or ex • ge, according to ORS 447, 449, 670, and 701. Branch circuits — new, alteration, or extension, per panel
Owner signatur,.'• Date: _3 /0 _ r A. Fee for branch circuits with
1t t ' eac branch circuit eder fee,
7.42 2
Business name: B. Fee for branch circuits without
service or feeder fee, first 1 56.18 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 67.84 2
City/State /ZIP: dwelling, service and/or feeder
Reconnect only 67.84 2
Phone: ( ) Fax : :( )
Pump or irrigation circle 67.84 2
E -mail: Sign or outline lighting 67.84 2
0. `I 0 3R ._, „ Signal circuit(s) or limited - energy
panel, alteration, or extension. Page 2 2
Business name:
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
Investigation (1 hr min) 66.25/ hr
City/State /ZIP: Industrial plant (I hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00/ hr
specifically listed C. /2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: „ '
E RICAL; IT ;EKES
Subtotal: 56.18
Suprv. Electrician signature, required: Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): 6.74
TOTAL PERMIT FEE: 62.92
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: * Number of inspections allowed per permit.
I:\ Building \Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(11/05 /COM/WEB
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 the Construction Contractors Board.
or -
`-1 ` II 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.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
/
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Print Name of Permit Applicant
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Signature of Permit Applican Date
Permit #: B t./Wei I — Ck )67 I /I✓i�. - ?tiil — X 4 _N: ?
Address: i 5- 05C . I. �7 I 4 Y • -='.-',o'• 4. ,4 i i , ,,,
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Issued by: `3 ? - Date: 3/ IC/ I I
This Copy for Permit Offices