Permit CITY OF TIGARD ELECTRICAL PERMIT
11111 • COMMUNITY DEVELOPMENT Permit #: ELC2011 -00360
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/28/2011
Parcel: 2S109DA16100
Jurisdiction: TIGARD
Site address: 15468 SW SUMMERVIEW DR
Project: Arlington Heights No. 3, lot 80 Subdivision: ARLINGTON HEIGHTS NO. 3 Lot: 80
Project Description: Temporary service.
Contractor: CITY ELECTRIC & SUPPLY CO Owner: COLUMBIA STATE BANK
22235 SW SCHALTENRAND LN BY JECK, AL
SHERWOOD, OR 97140 17800 SE MILL PLAIN BLVD, STE 10
VANCOUVER, WA 98683
PHONE: 971 -404 -1714 PHONE:
FAX: 503 - 625 -3052
FEES
Quantity Description Date Amount
1 ea Temp Services or Feeders - 06/28/2011 $59.36
Specifics: 200 amps or less
1 ea 12% State Surcharge - 06/28/2011 $7.12
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $66.48
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: • 2 -001 -0090. You m -y o•tain a c.. • of the •ir • =i ect questions to OUNC by calling 503.232.1987 .800.33 44,
Issued By: f f- /.1c 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 W Tigard, t 5) FOR OFFICE USE ONLY
CI of Ti and ` ' t‘`
Received / / Permit No.: /
`J ► � iv t(-/S a
S Ha ll g Blvd., O � Plan Review
I IIII 0 ar 13125 Phone: 503.639.4171 Fax: 5 03. �� �Q� Date e /B : t0 i! L td Other Permit:
7' I G A R D Inspection Line: 503.639.4175 ,,\\''> t+ V�" O* Date Ready/By: Se e Page 2 for
Internet: www.tigard- or.gov J �N ,0
D► Notified /Method: Supplemental Information
O TYPE OF WOR � PLAN REVIEW
NI
[ New construction ❑ Addition/alteratio • ement Please check all that apply (submit 2 sets of plans w /items checked below):
.Oa
r ❑ 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.
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.
❑ 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 13 ,
Job no.: 14.5 Job site address: i ( ti c.:,- I00HP or more. occupancy.
V v�W +� r 1 Ve 0 or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: Tigard, OR 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: Arlington Heights ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Arlington Heights Lot no.: SO 1,000 sq. ft. or less 168.54 4
Ea. add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 67.84 2
Limited energy, multi- family
67.84 2
reined (6i1st ' (��,. L - residential (with above sq. ft.)
0� I j / I V f1� Services or feeders installation, alteration, and /or relocation
200 amps or less 100.70 2
® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: Stone Bridge Homes 401 amps to 600 amps 200.34 r 2
601 amps to 1,000 amps 301.04 2
Address: 16869 SW 65th Avenue #505 Over 1,000 amps or volts 552.26 2
City /State /ZIP: Lake Oswego, OR 97035 Temporary services or feeders installation, alteration, and/or
relocation
Phone: (503)387 -7577 Fax: (503)387 -7615 200 amps or less i 59.36, n, 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 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
Owner signature: Date: Branch circuits – new, alteration, or extension, per panel
A. Fee for branch circuits with
® APPLICANT I ❑ CONTACT PERSON above service or feeder fee,
each branch circuit 7.42 2
Business name: SEE ABOVE B. Fee for branch circuits
Contact name: without service or feeder fee, 56.18 2
Deirdre Britt first branch circuit
Address: Each add'I branch circuit 7.42 2
Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 67.84 2
dwelling, service and /or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
E -mail: dbritt @stonebridgehomesnw.com Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
Business name: City Electric Signal circuit(s) or limited -
energy panel, alteration, or
Address: 55568 SW Schaltenbrand Lane extension. Describe: Page 2 2
City /State /ZIP: Sherwood, OR 97140 Each additional inspection over allowable in any of the above
Per
Phone: (971) 404 -1714 Fax: (503) 625 -3052 inspection 66.25
per hour (I hr min) 66.25
CCB Lic.: 42422 Electrical Lic.: 26 -289C Suprv. Lic.: 35925 Industrial plant per hour 78.18
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: A
Subtotal:
Print name: Chuck Friesen Date:
Plan review (25% of permit fee): —
State surcharge (12% of permit fee): 7 / i 0 I,
Authorized signature: TOTAL PERMIT FEE: 062 , 'Tr
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.
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