Permit CITY OF T I G A R D ELECTRICAL PERMIT
RESTRICTED ENERGY
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- 13125 DEVELOPMENT H PMENT Tigard, (503) 639 -4171 DATE ISSUED: ED: 8% 4/2004
SITE ADDRESS: 12240 SW ANN CT PARCEL: 2S103BB 13100
SUBDIVISION: LAKE TERRACE NO. 2 ZONING: R -4.5
BLOCK: LOT: 024 JURISDICTION: TIG
Project Description: Limited energy.
A. RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: X AUDIO & STEREO: INTERCOM & PAGING:
BURGLAR ALARM: X BOILER: LANDSCAPE /IRRIGAT:
GARAGE OPENER: CLOCK: MEDICAL:
HVAC: DATA/TELE COMM: NURSE CALLS:
VACUUM SYSTEM: FIRE ALARM: OUTDOOR LANDSC LITE:
OTHER: ALL ENCOMP : X HVAC: PROTECTIVE SIGNAL:
INSTRUMENTATION: OTHER:
• TOTAL # OF SYSTEMS:
Owner: Contractor:
KURTIS SIXEL TELEPHONE CONNECTION SERVICE
3472 NW 115TH PO BOX 2075
PORTLAND, OR 97229 BEAVERTON, OR 97075
Phone: 503 -528 -1100 Phone: 642 -7374
Reg #: LIC 50013
ELE 34- 142CLE
SUP 458LEA
FEES Required Inspections
Description Date Amount Low Voltage Inspection
[ELPRMT] ELR Permit 8/24/2004 $75.00 Elect'l Final
[TAX] 8% State Surchar€ 8/24/2004 $6.00
Total $81.00
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.
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Issued by � ���Ps -e�l�� 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'N DATE:
LICENSE NO:
Call 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Electrical Permit A WIQWWED .
„ .
. . .
... . FOR OFFICE USE ONLY
Receive< ,
13125 ) M
City ef Tigard
SW Hall Blvd .., ../ /A Permit No.: 6 ., Tigard, OR 97AUG 2 4 2004 A, Date/By: A •
Plan Review '
Phone: 503.639.4171 Fax: 503.598.1960 a k: 14111A0 Date/I3 : Other Permit:
TIGA
Inspection Line: 503.639.4175 c ii-JA11., ot i i . Date Ready/By: ran El See Page 2 for
Internet: www.ci.tigard.or.us CITY OF RD — Notified/Method: Supplemental Information
4Elinl:rtfit4/V444044.mM4b,ty,p 0 0F6iiire A•:: ., . • . •
-,. '4. - 440-z-." kr.a ,,,,,, , ,,,,,,,, ,,,,,,,-: ,, r .,4, ,.• ', . • •
El New construction R AdditionIa1terationIrep1acement . Please check all that apply:
EService over 225 amps, comm'l EHazardous location
0 Demolition E Other:
_ „ EService over 320 amps — rating EBuildng over 10,000 sq. ft.,
irf:41" 5:11§i*111,0f6Aliadr of 1- and 2-family dwellings 4 or more new residential
f - and 2 dwelling IE Commercial/industrial 111 Accessory building 0System over 600 volts nominal units in one structure
nBuilding over three stories OFeeders, 400 amps or more
[1] Multi El Master builder ['Other:
, „ COccupant load over 99 persons EManufactured structures or
i•T• iAt i kNli
iMlar i-oZ•gfifiW"'KMgwit,E'' ,E' '' gli 0 Egress/lighting plan RV. park
1• ,,t4tip-,•••.;,,.,,,,',• ••:::''.;:
1:IHealth-care facility ['Other:
Job no.: Job site address: (? 3 tip (..4 Au c
Submit 1 . sets of plans with any of the above.
City/State/ZIP: 710/77.I2 60---efeA The above are not applicable to temporary construction service.
iTi3i4Ifirgr .:"...'• '' - . ''
Suite/bldg./apt. no.: Project name:
Description Qty. Fee. Total **
Cross street/directions to job site: 1),4./ / j 2 q r*frae- New residential single- or multi-family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 4
Subdivision: Lot no.: Ea. add'l 500 sq. ft. or portion 33.40 I
Limited energy, residential 75.00 i 2 •
Tax map/parcel no.: .
Limited energy, non-residential 75.00 2
itantintEMTMATE4W1 trigriatnitatit Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Te-Qepflox.e., a -n) 5 re,eee Sao g., ty i C.A.)4ely cow reoL Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
Witi Q; mie; 201
amps to 400 am amps 106.85 2
i.ke,,i'ai..v.M:;.'2%!„,....., :',.& ,,Z44',4% 4 . .''!:4a - liktrM.,ila0E-
amps to 600 ps 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) Fax: ( )
200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 2
Owner signature: Date: Branch circuits — new, alteration, or extension, per panel
lie*.i:W.7',V55: ,.: 4 VApIiirre,U:"T 1, :::7;':;:::: , ;SW:;:li pgr'i.7.'VWeoWRVtp A. Fee for branch circuits with
iii TIA7 -iv, ',..:4 service or feeder fee, each
6.65 2
Business name: branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee,
each branch circuit 46.85 2
Address:
Each addl branch circuit 6.65 2
City/State/ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle 53.40 2
Phone: ( ) Fax: : ( )
Sign or outline lighting 53.40 2
E Signal circuit(s) orlimited-
ragAtOPMPIA=4:,.tIVAMAArAt4fatulitc 5opp i fi- : ggt - y7N - Ann energy panel, alteration, or
extension. Describe: Page 2 2
Business name: T2°/4 e,A.,6 de 564illaz
Address: p,Of 6 0)C 00 75 Each additional inspection over allowable in any of the above
Per inspection 62.50
City/State/ZIP: 6e,40 a, q 70 75 Investigation per hour (1 hr mm) 62.50
Industrial plant per hour 73.75
Phone: (193 ) 4 y . 737y Fax: (5,3 ) A; cid-- 6/S5D
lifiSign:MtttgirOaalSWITCA:C='7:
CCB Lic.: 6..) 3 Electrical Lic.: 3 t /_/i Suprv. Lic.: cHs t.44
Subtotal 7s ' , t
Suprv. Electrician signature, required: al) V ez a .a.. ., Plan review (25% of permit fee) ---
State surcharge (8% of permit fee) &an)
Print name: lc otH4.i Date: ,A y la e i
TOTAL PERMIT FEE br
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete
Print name: Date: * Fee methodology set by Tri-County Building Industry Service Board
0 * Number of inspections per permit allowed.
iABui1dingTerrnits \ELC-PermitApp.doc 12/03 440-4615T(10/02/COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RE IDE TI :W a lt(TOA M-, kb` < l N .
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
•
Fee for each commercial system $75.00
(SEE OAR 918- 260 -260)
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
•
❑ Landscape Irrigation Control*
❑ 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- PeamitApp.doc 04/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
BUP
Received / Date Requested / - —/ AM PM BUP
Location / ( • Suite MEC
Contact Person Q P - h ( ) 6 ( 6)- - 7 37 PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation , ELC
g Access: ELR :doo q - C) - a '7/
Ft Drain
Crawl Drain .
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation •
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling '
Roof
Other: '
Final
PASS PART FAIL
;PLUMBING; - - ° :' _: .
Post & Beam
Under Slab
Rough -In �
Water Service
Sanitary Sewer C %
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
' MECHANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL _, _
•
Service
Rough -In
UG /Slab
Low Voltage
�� Fir :_. larm
�i6l#`'" PART FAIL
0 Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
t 0 Please call for reinspection RE: / El Unable to inspect — no access
Fire Supply Line
ADA
Approach /Sidewalk Date / 0 / Inspector -.410... Ext
Other:
Final DO NOT REMOVE this inspection record from the Job site.
PASS PART FAIL