Permit CITY OF TIGARD ELECTRICAL PERMIT
``1 COMMUNITY DEVELOPMENT Permit #: ELC2011 -00175
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/06/2011
Parcel: 1 S133DB00104
Jurisdiction: TIGARD
Site address: 11450 SW WINTERLAKE DR
Project: SUMMERLAKE DOG PARK Subdivision: Lot:
Project Description: 200 amp sub panel.
Contractor: MR ELECTRIC OF CLARK COUNTY Owner: TIGARD, CITY OF
14300 NE 20TH AVE. D102 -313 13125 SW HALL BLVD
VANCOUVER, WA 98686 TIGARD, OR 97223
PHONE: 360- 574 -7200 PHONE:
FAX: 360- 546 -2158
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 04/06/2011 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 04/06/2011 $12.08
Type of Use: COM 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. 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 0 • 52- 001 -0090. You may obtain a co v of the rul que to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By . _ _ _ — - - rmittee Signature: - � -
• WNER 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.
Apr. 6. 2011 1: 47AM ` No. 6744 P. 2/3
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard Received �fI
,. , -- • ` 13125 SW Hall Blvd., Tigard, OR 97223 Plea Review
i Phone: 503.718.2439 Fax: 503,598.1960 Date/Il:
Other Permit:
T I i.i A R D Inspection Line: 503.639.4175 Date Ready/By: Ed See Page 2 for
Internet: www,tigard-orgov Notified/Method: I 1 Supplemental Information
E OF WORK PLAN REVIEW
0 New construction Addition /alteration /replacemerlt 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.
CATEO OF CONSTRUCTION exceeds 10.000 amps at 150 volts or 0 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.
El Multi - family ❑ M aster builder U] Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of now motor load of ❑ "A ", "E ", "1.2", "1.3 ",
lob n0 -: s (C ~- � lo 1 a, 1001{P or store. occupancy.
Q 7W �V t Y \ W ❑ Six or more residential units, ❑ Recreational vehicle parks.
City /State /ZIP: ��G�Y`Gt 'A f/ ❑ Health - care facilities. El Supply voltage for more than
�, O [� c / � 1 (2 ' Z3 ❑ llasatdous locations. 600 volts nominal.
Suite /bldg. /apt. no.; Project name: //��r� U Ti If Ss , ;.4 „,, ❑ Service or feeder 600 amps or more.
tJ1 ry FEE SCHEDULE
Cross street/directions to job site: f f 0..010. 1 Rrv. I Pee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. P. or less 168.54 4
Tax map /parcel no.: Ea. add'l 500 sq. ft. or portion 33.92 I
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. n.) _
Limited energy, multi- family
1--4.0 d D Wtp l h .- Ve 1 residential (with above sq. ft.) 75.00 2
"� y Services or feeders installation, alteration, and /or relocation
200 amps or less MI 100.70 rifi, , 7 2
PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: C: 0 1 � 401 amps to amps 200.34 2 -
. _ 601 amp to 600 1,000 amps 301.04 2
Address: , S� ' \ Tit Over 1000 amps or volts u 552.26 2
City /State /ZIP: (0 /a `L �l � Temporary services or feeders Installation, alteration, an
\�OT 11i� ` � 1 A relocation
Phone: (j 031 '4 l.s ` Fax; ) ". l i Q 200 amps or less 59.36 1
Owner installation: This installation is being made on properly that I own which is not 201 amps to400 amps 125.08 2
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 wirh
❑ APPLICANT 'CONTACT PERSON above service or feeder fee,
7A2 2
each branch circuit
Business name;
- r pt� ne u a k. � 0 ?e , B. Fee for branch circuits without
V service or feeder fee, first
Contact name: ��\rvaLob\oS. branch circuit 56.18 2
Each ad I d'I branch circuit � 7.42 12
Address: \ 1k r 2 `2,_ ^ ' Miscellaneous (service or feeder not Included)
, Each manufactured or modular
City /State /Z1P: /Oyt vpt� (J.) 1\ ` (� 1Vl-0 dwelling, service and/or feeder 67.84 2
Phone: ISt 2., (p - as I Fax; : ( 0S14(t) " 2-1sg Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail: CS'I \I\ e ) ,‘ , ..4.-; ,_C_ , Up t/1,■._ Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited - energy
Business name: IAN panel, alteration, or extension. Page 2 2
I dL \(ulJlt n c C�l� f�� MY .' ( G`v` C Each additional inspection over allowable in any of the above
Address. 114 3 ' 0 1 3 .)C ' ' ' ' •P&R,_ W.. _ 3\ 3 Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP; t71� (.. J \'y-- W Investigation (I hr min) 66.25/hr
lP 0 4 � Industrial plant (1 hr min) 78.18 / hr
Phone: ) 2 (p, «C�''S S _ 1 Fax: gb0) S l f t _ z 1 Inspections for which no fee is
90.00/ hr
specifically listed 05 hr min)
CCB Lic.[0C6'2 J • I Electrical L•c.: (J3( I Suprv. I.ic.: 1 15V5 ELECTRICAL PERMIT FEES
Subtotal: 100 .'C)
Suprv. Electrician signature, required: • Plan review (25% of permit fcc):
Print name: ,. . t . / • V . Date!' ,h 1 State surcharge (12% of permit fee): 11,0
Y A �i ' I _ TOTAL PERMIT PEE: 112 ."1%
Authorized si nature . i to -4 -
g W t �� 0P : This permit application expires if a permit is not obtained within 180
ww days after it has been accepted as complete.
Print name: ■ , �� a.tf Date. r Number of inspections allowed per permit.
C' Fuildin g\PermitslELC- PermitApp.doa 07101/10 440.4615t(l lla5/COMA/EB