Permit CI TY OF TIGARD ELECTRICAL PERMIT
PERMIT #: ELC2003 -00630
T DEVELOPMENT SERVICES DATE ISSUED: 10/14/03
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 PARCEL: 2S1036B 02100
SITE ADDRESS: 12195 SW 124TH AVE
SUBDIVISION: BROOKWAY ZONING: R
BLOCK: LOT : 021 JURISDICTION: TIG
Project Description: Replace gas furnace
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL /PANEL:
MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
CORY STEETER OWNER
12195 SW 124TH
TIGARD, OR 97223
Phone: 503 - 793 - 2379 Phone:
Reg #:
FEES
Description Date Amount
Required Inspections
[ELPRMT] ELC Permit 10/14/03 $46.85
[TAX] 8% State Tax 10/14/03 $3.75 Elect'l Final
Total $50.60
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set
forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC at (503) 246 -6699 or
1- 800 - 332 -2344.
Issued By: l Permit 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'N: DATE:
LICENSE NO:
Call 639 -4175 by 7:00pm for an inspection the next business day
Electrical Permit Application FOR OFFICE USE ONLY
PP Received Electrical
Date /By: ( l ( Li i 0 3 Permit No 3 ( o
Cl of Tigard Planning Approval Sign
City g Date /By: Rev iew
Permit No.:
Plan
13125 SW Hall Blvd. Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503 - 598 -1960 Post- Review Land Use
" (A '''\ � I I DateDate/By: Case No.:
Internet: www.ci.tigard.or.us .' = Contact Juris.: ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 --� Name /Method: Supplemental Information.
TYPE OF WORK PLAN REVIEW (Please check all that apply)
❑ New construction ❑ Demolition ❑ Service over 225 amps- ❑ Health -care facility
commercial ❑ Hazardous location
Addition/alteration/replacement ❑ Other: ❑ Service over 320 amps- rating of ❑ Building over 10,000 square feet,
CATEGORY OF CONSTRUCTION 1 & 2 family dwellings four or more residential units in
J1 & 2- Family dwelling ❑ Commercial/Industrial ❑ System over 600 volts nominal one structure
ri ❑ Building over three stories ❑ Feeders, 400 amps or more
❑ Accessory Building El Multi -Famil Multi-Family ❑ Occupant load over 99 persons ❑ Manufactured structures or RV park
❑ Master Builder ❑ Other: ❑ Egress/lighting plan ❑ Other:
JOB SITE INFORMATION and LOCATION Submit sets of plans with any of the above.
The above are not applicable to temporary construction service.
Job site address: /? /' t✓J / V1 /1'v FEE* SCHEDULE
Suite #: Bldg. /Apt. #: Number of inspections per Permit allowed
Project Name: Description Qty Fee (ea.) Total
Cross street/Directions to job site: New residential - single or multi - family per 1
dwelling unit. Includes attached garage.
Service included:
1000 sq. ft. or less 145.15 4
Each additional 500 sq. ft. or portion thereof 33.40 1
Subdivision: Lot #: Limited energy, residential 75.00 2
Limited energy, non residential 75.00 2
Tax map /parcel #: Each manufactured home or modular dwelling
DESCRIPTION OF WORK service and/or feeder 90.90 2
.
/ _(�n_/?. / Services or feeders - installation,
A .. I t� /Vt Gt .. E' / l/1 S U C alteration or relocation:
re Co -e - 200 amps or less 80.30 2
�� 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
PROPERTY OWNER 1 ❑ TENANT 601 amps to 1000 amps 240.60 2
/ Over 1000 amps or volts 454.65 2
Name: � jr y �74T�o r Reconnect only 66.85 2
Address: /2/9 / c SG . / Z V 13- /11v C Temporary services or feeders - installation,
City/ State/Zip: alteration, or relocation:
ty p / / C fV21 200 amps or less 66.85 1
Phone: ' Fax: 201 amps to 400 amps 100.30 2
�� , � `, 3 - s
p 401 to 600 amps 133.75 2
0 APPLICANT ❑ CONTACT PERSON Branch circuits - new, alteration, or
Name: 5 li Wt L extension per panel:
Address: A Fee for branch circuits with purchase of
service or feeder fee, each branch circuit 6.65 2
City /State /Zip: B. Fee for branch circuits without purchase of (��
service or feeder fee, first branch circuit ' 46.85 1 7 1 40 , .. 2
Phone: Fax: Each additional branch circuit 6.65 2
E -mail: Misc.(Service or feeder not included):
CONTRACTOR Each pump or irrigation circle 53.40 2
Each sign or outline lighting 53.40 2
Job No: Signal circuit(s) or a limited energy panel,
Business Name: (9 LY f E /L alteration, or extension Page 2 2
Description:
Address:
City /State/Zip: Each additional inspection over the allowable in any of the above:
y h Per inspection per hour (min. 1 hour) 62.50
Phone: Fax: Investigation fee:
CCB Lic. #: Lic. #: Other:
Electrical Permit Fees*
Supervising electrician Subtotal $ L/ , S
signature required: Plan Review (25% of Permit Fee) $
Print Name: Lic. #: State Surcharge (8% of Permit Fee) $ 3 , `7
TOTAL PERMIT FEE $ ` 77 , Q
Authorized /�7 Notice: This permit application expires if a permit is not obtained within
Signature: �� � A Date: I!� / ((/) 180 days after it has been accepted as complete.
2 *Fee methodology set by Tri- County Building Industry Service Board.
/ (Please print name)
is \Dsts\Permit Forms \ElcPermitApp.doc 01/03
Electrical Permit Application - City of Tigard •
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all systems $75.00
Check Type of Work Involved:
ri Audio and Stereo Systems
n Burglar Alarm
I I Garage Door Opener
ri Heating, Ventilation and Air Conditioning System
Vacuum Systems
n Other
COMMERCIAL WORK ONLY:
Fee for each system ... $75.00
(SEE OAR 918- 260 -260)
Check Type of Work Involved:
E Audio and Stereo Systems
• Boiler Controls
n Clock Systems
E Data Telecommunication Installation
Fire Alarm Installation
HVAC
n Instrumentation
n Intercom and Paging Systems
17 Landscape Irrigation Control
n Medical
• Nurse Calls
ri Outdoor Landscape Lighting
n Protective Signaling
n Other
Number of Systems
* No licenses are required. Licenses are required for all
other installations
i:\Dsts\Permit Forms \ElcPermitAppPg2.doc 01/03
CITY OF TIGARD , 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
j BUP
Received Date Requested / 4 /5` AM PM BUP
Location / a / / ,--- / 7 Suite MEC 3 — D 5
Contact Person Ph ( ) PLM
Contractor Ph ( ) SWR
BUILDING Tenant/r1 )0 9 3-7,, 9 ELC .— a 0 Co 3 0
Footing
Foundation ELC
Ftg Drain Access: e V J � /}� b v ELR
Crawl Drain Y
Slab Inspection Notes: - SIT
Post & Beam -�
Shr Ext SShea th / ear , / OD 't.
Ext heah/h
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam (� r 0 f 1 (a
Under Slab \l '�S k',, iv> �` --o ,
Rough -In �I� K U
Water Service T r v ' k ' O
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL
Post & Beam
Rough-In Line
a Line l /._/ /19it---------------
Gas
Smoke Dampers
' PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fires Al rm
in
PART FAIL 0 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
SITE ❑ Please call for reinspectio RE: 4 4 Unable to inspect — no access
Fire Supply Line
r
Approach/Sidewalk Date e) _ G Inspect . air ,A.,.. J if •' Ext
Other:
Final DO NOT REMOVE this inspection record fr u m the jo te.
PASS PART FAIL