Permit CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2011 -00196
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/14/2011
Parcel: 1 S136AD04000
Jurisdiction: TIG
Site address: 11509 SW PACIFIC HWY
Project: VILLELA THERAPUTIC CENTER Subdivision: Lot:
Project Description: Electrical for TI.
Contractor: ELECTRICAL CONTRACTOR SERVICES N.W. Owner: SMITH, EDITA M
PO BOX 1233 833 NW 170TH DR
ST. HELENS, OR 97051 BEAVERTON, OR 97006
PHONE: 503 - 922 -1812 PHONE:
FAX: 503 - 296 -5518
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 04/14/2011 $100.70
Specifics: amps or less
6 crt Branch Circuits w /Purchase 04/14/2011 $44.52
Type of Use: COM Service or Feeder
Class of Work: ALT 1 ea 12% State Surcharge - 04/14/2011 $17.43
Electrical
Type of Const:
Occupancy Grp:
Total $162.65
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 OAR •52- 001 -0090. You ma obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature: ,r
' 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 Applicatio "DECEIVED FOR OFFICE 1:SE ONLY
City of Tigard Received Date,43 : MAIM Permit No.: LC • _ • 4
I - I3L25 SW Hall Blvd., Tigard, OR 97223 AA Plan Review / _
Phone: 503.718.2439 Fax: 503.548.1960r R 1 3 7 O J 1 Other Permit: ` /
T Ci A R D Inspection Line: 503.639.4175 Date Ready /By- El See Page 2 for
Internet: www.tigard CITY OF TIGARD Notified /Method: MI Supplemental Information
TYPE oFI rADING DIVISION PLAN REVIEW
❑ New construction ® Addition/alteration/replacement Please check all that apply (submit 2 sets of plena writems checked below).
❑ Service or feeder 400 amps or more ❑ 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.
loss 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: 0 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" "l -2" I -3"
100HP or more. occupancy.
Job no.: 11614 Job site address: 11509 SW Pacific Hwy
❑ Six or more residential units. ❑ Recreational vehicle parks. • City /State /ZIP: Tigard, OR 97223 ❑ Health -cart facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 60D volts nominal.
Suite/bldg. /apt. no.: Project name: Human Collective ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: questions ?Ron Taylor 503 312 5000 Description I Qty.J Pee. I Total I •
New residential single- or multi- family dwelling u nit.
Includes attached garage.
Subdivision: . Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add') 500 sq. ft. or portion 33.92 I
Tax map/parcel no.:
Limited energy, residential 7500 2
DESCRIPTION OF WORK (with above sq. ft)
Limited energy, multi -family 75.00 2
60amp panel, 6 circuits for outlets residential (with above sq. ft) .
Services or feeders installation, alteration, and/or relocation
200 amps or less 1 100.70 100.70 2
0 PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or vohs 552.26 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
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, per panel _
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 6 7.42 44.52
each branch circuit
Business name: B. Fee for branch circuits teifhoui
service or feeder fee, first 56.18 2
Contact name: branch circuit ,,
Each add' I branch circuit i 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84
dwelling, service and/or feeder
Phone: ( ) I 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: Electrical Contractor Services NW panel, alteration, er extension. Page 2 , 2
Each additional inspection over allowable in any of the above
Address: P 0 Box 1233 Additional inspection (I hr min) 66.25i hr
Investigation (1 hr min) 66.25i hr
City/State/ZIP: St Helens, OR 97051 Industrial plant (I hr min) • 78.18i hr
Phone: (503) 9221812 I Fax: (503) 296 5518 Inspections for which no fee is 90.00i hr
. . specifically listed (% hr min)
CCB Lie.: 155460 Electrical L' C Suprv. Lic.: 3289S ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: { subtotal: 145.22
_ - r� Plan review (25 %of permit fee): .
Print name: Paul Oliverio r ,� a � 1 11 . State surcharge (12% of permit fee): 17.43
TOTAL PERMIT FEE: 162.65
Authorized signature• 1 `
1'111.] 11 — - p cl ts 1h t� C tai - s r t ni F T This permit application expires it a permit is not obtained within 180
Print name: + Date: days after it has been accepted as complete. q e o , t,
Number o inspections allowed per permit. CL ti
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