Permit �
CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2009-00372
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/24/2009
Parcel: 2S103BB07901
Jurisdiction: Tigard
Site address: 12350 SW 124TH AVE
Subdivision: LAKE TERRACE Lot: 8
Project: Hinds
Project Description: Reconnect A/C, add GFCI Cony. outlet
Owner: FEES
HINDS, TOM M & JUDY G Quantity Description Date Amount
12350 SW 124TH AVE
TIGARD, OR 97223 1 crt Branch Circuits w /Purchase 07/24/2009 $6.65
Service or Feeder
PHONE: 1 crt Branch Circuits 07/24/2009 $46.85
wo /Purchase Service or
Feeder
Contractor: 1 ea 12% State Surcharge - 07/24/2009 $6.42
PRO CIRCUIT ELECTRIC LLC Electrical
PO BOX 3948
WILSONVILLE, OR 97070
PHONE: 971 - 563 -8211
FAX: 503 - 266 -1349
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $59.92
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 OAR 952- 001 -0100. You m{a /y� obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: C Permittee Signature: !J X.
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 an inspection that business day.
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 AROlicatio C FOR 01 F 15L O" I.
r r I� • Date/By: Permit No.: ELC- eel -1 ?-
h•d
• 13125 SW Hall R., Tigard, OR 97223 Plan Review Other Permit:
_ • City of Tigard is ��// a
Phone: 501639.4171 Fax: 503.598.1960 JUL 2 4 ZOOS Date/By:
Inspection Line: 503.639.4175 Date Ready/By: ha's: I El Sec Page 2 for
T t G A R D Notified/MethoA: Supplemental Information
Interact: veww.ligard- or.gov
CITY OF TIGARD
TYPE OF W 1 t i ^, 'DIVISION PLAN REVIEW
calf Vii.
Please check all that apply (submit i sets of {dens w (items checked below)
❑ New construction 12cRddition/alteratian /replacement S or feeder 400 amps or more 0 Building over three stocks.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
r CATEGORY OF CONSTRUCTION exceeds 10.000 amps at 150 volts or ❑ Floating buildings.
less to ground, oc exceeds 14,000 ❑ Commercial -use agneultaral
S.,J and 2 family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Fire pump. ❑ Installation of 75 KV A or
❑Multi family ❑ Master builder ❑Other: ❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ['Addition of new motor load of ❑ "A", "E', "1 - ", '1'3",
100HP or more. occupancy.
Job no_: Job site address: I 1-55, 50 \ ‘7.47 ❑ Six or more residential units. ❑Recreational vehicle parks.
❑ Health -cme facilities. O Supply voltage for more than
CityiStatelZlP: ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt no.: Project name: O service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Peseription I Otv. 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 145.15 4
_ Ea add'1500 sq. ft. or portion _ 33.40 1
Tax map/parcel no.: _ Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. It )
Limited energy, multi- family 75.00 2
( e U A.-/— fi n ix CoFC CDP3J aJ I +4-
residential (with above sq. R.)
Services or feeders installation. alteration, and/or relocation
200 amps or less 80.30 r 2
PROPERTV OWNER ❑ TENANT 201 amps to 400 amps 106 2
40) amps to 600 amps 160.60 2
Name: �� � l/ � + 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
Temporary services or feeders installation, alteration, and/or
CitylState/ZIP: relocation
' Phone: ( ) Fax: ( ) 200 amps or less 66.85 1
201 amps to 400 amps 100.30 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 133.75 2
Branch circuits— new, alteration, or extension, er enc!
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee, �
6.65 t (ti') 2
each branch circuit l
Business name: B. Fee for branch circuits ,
without service or feeder fee, i 46.85 b ( n � V 7 '
Contact name: first branch circuit
Each add'/ branch circuit 6.65 _ 2
Address: Miscellaneous (service or feeder not included)
City /State/ZIP: Each manufactured or modular 90.90 ' 2
dwelling, service and /or feeder
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
E-mail:
Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline Sighting 53.40 2
Signal circuits) or limited- r
Business name: D t . `I- energy panel, alteration or
Address: .0 s b 3:1 LI 5 extension. Describe: Page 2 2
City /State/ZIP: A n . (, 0 ‘ °7. t? Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (q n( } %3 8 k Fax. ( ' zw ( 349 Investigation per hour() hr min) 62.50
CCB Lic.: y Electrical Lie.: ; --fop f,._ 516"7 per Suprv. Lie.: 5 Industrial plant per hour 73.75
1 no \\ erh K'►L PERMIT FEES
Suprv. Electrician signature. required: i ,_ Subtotal: 53 .
` Plan review (25% of permit fee):
Print name: l F � �� l Bate:
� State surcharge (12% of permit feu): �. y 'Z
Authorized signature: TOTAL PERMIT FEE: I , 1- - This permit application expires if at permit is not obtained within 1511
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
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