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Permit CITY OF TIGARD ELECTRICAL PERMIT ,„ . °' COMMUNITY DEVELOPMENT Permit #: ELC2011 -00282 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/25/2011 Parcel: 2S103BB11900 Jurisdiction: Tigard Site address: 12120 SW ANN PL Project: LEATHERS Subdivision: YE OLDE WINDMILL Lot: 38 Project Description: (1) branch circuit for bathroom remodel. Contractor: OWNER Owner: LEATHERS, CRAIG R & DONNA 20739 SW SKIVER ST ALOHA, OR 97007 PHONE PHONE: FAX: FEES Quantity Description Date Amount 1 Gil Branch Circuits wo /Purchase 05/25/2011 $56.18 Specifics: Service or Feeder 1 ea 12% State Surcharge - 05/25/2011 $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 through OA' •52- 001 -0090. You may obtain a copy • or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: ✓ /_�_< / • Permittee 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' 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 FOR OFFICE USE.ONLY City of Tigard ® 13125 SW Hall �� Received 4 Permit No.: �—^ l 7- Blvd., Tigard, OR 9722 1 Plan Review 0 l '�� x Other Permit: �/�� + , Cpl Phone: 503 Line: 503639 4 39 Fax: 5 03 . 5 4'x Date/By: �i ' �llllJ I I k 1� 1 T,I GA R D Inspection Line: . �. Date Ready/By: Juris: ® See Page 2 for Internet: www.tigard or.gov ��, � �� ....\ Notified/Method: Supplemental Information TYPE OF WOITK \ Q fA - `\,,, PLAN REVIEW ❑ New construction Addition a terati '�15t 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: J .0. N9 where the available fault current ❑Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural IP. 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 JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "l -3 ", Job no.: Job site address: l2AZr) a, . ,n Al 100 or or more residential R occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks City /State /ZIP: ` I ZZ ❑ Health -care facilities. ❑ Supply voltage for more than �`^ I ❑ Hazardous locations. 600 volts nominal Suite /bldg. /apt. no.: Project name: tAD 10,j-3■ ❑ Service or feeder 600 amps or more. r �}— FEE SCHEDULE Cross street/directions to job site: 1st S 3 r�tS ,r`�7n 6 T IZk St s LWAALv.l Description I Qt I Fee. I Total 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'I 500 sq. ft. or portion 33.92 1 Tax map /parcel no.: Limited energy, residential 75.00 2 DESCRIPTION OF WORK (with above sq. ft.) C J Limited energy, multi- family 75.00 2 /Veil Ct y am; f— '4 ID �� residential (with above sq. ft.) l Services or feeders installation, alteration, and /or relocation 200 amps or less 100.70 . AMEROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: C fa,` - Z L c r t2 t 601 amps to 1,000 amps 301.04 2 Address: (Zl�2 Q `.J Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation, alteration, and /or City/State /ZIP: -- Cc Zrc1 t oe qt / Z Z 3 relocation Phone: ( 4 9 5 3 ) s o2 _ Goat 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 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, 9.nd 701. 401 amps to 599 amps 168.54 2 !/ Branch circuits – new, alteration, or extension, per panel Owner signatu Date: ( 5 J A. Fee for branch circuits with ❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee 7.42 2 each branch circuit Business name: B. Fee for branch circuits without service or feeder fee, first Contact name: branch circuit I 56.18 r I. 2 Each add'l 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 Phone: ( ) 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: , panel, alteration, or extension. Page 2 2 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 (1 hr min) 78.18/ hr Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00/ hr specifically listed (% hr min) CCB Lie.: Electrical Lie.: Suprv. Lie.: ELECTRICAL PERMIT FEES Subtotal: 57 r (r Suprv. Electrician signature, required: Plan review (25% of permit fee): Print n nos L Date: State surcharge (12% of permit fee): - 7 Li � « �S TOTAL PERMIT FEE: �, III ure: Author' ed signat - 1 — This permit application expires if a permit is not obtained within 180 Print name: Date: ( / / // days after it has been accepted as complete. • Number of inspections allowed per permit. I:\ Building \Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(I1/05 /COM/WEB Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: Fee for all residential systems combined $75.00 Check Type of Work Involved: n Audio and Stereo Systems* ❑ Burglar Alarm n G • arage Door Opener* n H eating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* n Other: COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems I Landscape Irrigation Control* n Medical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I: \ Building \Permits\ELC- PermitApp.doc 07/01/10 r i Information Notice to Owners About v,°.• ; � Construction Responsibilities rl (ORS 701.055 (5)) Homeowners acting as their own general contractors to construct a new home or make a substantial improvement to an existing structure, can prevent many problems by being aware of the following responsibilities: • Homeowners who use labor provided by workers not licensed by the Construction Contractors Board, may be considered an employer, and the workers who provide the labor may be considered employees. As an employer, you must comply with the following: • Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Department of Revenue at 503 - 378 -4988. • Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503 - 947 -1488. • Oregon's Business Identification Number (BIN): is a combined number for both Oregon Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms. • .Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs if one of your workers is injured on the job. For more information, call the Workers Compensation Division at the Department of Consumer and Business Services at 503 - 947 -7815. • Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax. For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov. Other Responsibilities of Homeowners: • Code Compliance: As the permit holder for a construction project, the homeowner is responsible for notifying building officials at the appropriate times, so that the required inspections can be performed. Homeowners are also responsible for resolving any failure to meet code requirements that may be found through inspections. • Property Damage and Liability Insurance: Homeowners acting as their own contractors should contact their insurance agent to ensure adequate insurance coverage for accidents and omissions, such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not otherwise covered as employees by Workers Compensation Insurance. • Expertise: Homeowners should make sure they have the skills to act as their own general contractor, and the expertise required to coordinate the work of both rough -in and finish trades. CONSTRUCTION CONTRACTORS BOARD 700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052 Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007 Website Address: www.oreaon.gov /ccb f /property_owner adopted 12 -04 -07 This Copy for Permit Applicant 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 I will 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. Print Name of Permit Applicant ( Signs u rmit Applicant Date Permit #:u --fie? ( — c3 ` CbZ �1 � _ ) - - � / �y Address: l- t d 5 - �f'vr v /Z. * r'•< ri a►caI t oP 17d Issued by: g . / • Date: 5/95in This Copy for Permit Offices Location: Record Type: Inspection Type: Comments: Inspection Date: Record ID: Result: City of Tigard 13125 SW Hal Blvd. Tigard, OR 97223 Tel: 503.718.2439 12120 SW ANN PL, TIGARD, OR, 97223 Residential - Electrical 199 Electrical final 05/01/2013 00:00 ELC2011-00282 PASS - No C of O Violation Summary: Inspector Contractor