Permit CITY OF TIGARD ELECTRICAL PERMIT
r - COMMUNITY DEVELOPMENT Permit A. ELC2009 -00401
Date Issued 08/04/2009
.TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503 639 4171 parcel: 2S103DB09600
Jurisdiction Tigard
Site address: 11385 SW ERSTE PL
Subdivision- Lot 0
Project Culbertson
Project Description New feeder to new sub panel
Owner: FEES
CULBERTSON, JON C & BRENDA E Quantity Description Date Amount
11385 SW ERSTE PL 1 ea Services or Feeders - 200 08/04/2009 $80 30
TIGARD, OR 97223 amps or less
PHONE 1 ea 12% State Surcharge - 08/04/2009 $9 64
Electrical
Contractor.
JEROME ELECTRIC
PO BOX 751
HILLSBORO, OR 97123
PHONE 503 - 648 -5144
FAX 503 - 648 -9723
Type of Use. SF
Class of Work ALT Type of Coast
Occupancy Grp
Total $89 94
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 Atl 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 OOAA 952 -001 -0100 You may obtain a copy of the rules or direct questions to OUNC by calling 503 246 6699 or 1 8000332 2344 /
Issued By Ot( / — Permittee Signature CA/ 1 1 / /8 A �r rTf o /
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
e ,
,07/31/2009 12 5036489723 JERMOE ELECTRIC INC PAGE 01
, Electrical Permit Application FoR orrice USE ON .N
rved
City of Tigard RECEIVEItce e /fog 4444 Penns Noac.,zotg
13125 SW I loll Blvd , Tigard, OR 97223 Plan Review f2rher Penns
2 • t Phone, 503 619 4171 Fax 503.598,1060 Ontc /By
TIGARD Inspection l me 503639.4175 JUt 31 20030,itc Rcadv /By lam, El Scr rape 2 for
Intcrn<v wwwpgard -ur gov
Notified/Method. Supplemental lnfermannn
�� 0
d rie tlf ;All,9 h' r erryof!irtoARDi :;f,,;,ti r d, 'f,?,d,Pa l:',E� 4.' r ^. ,iB4`N:, 'Woa)
i ,'.j;li,�,,,H
❑ New construction [ ,( ddnion/ 8llerati onf6a0fclg'tlatlfnV1S�V:°i Please check
orfee apply( AoMn', 2 acts or plans whimschecked below)
❑ Service or feeder 400 amps or more ❑ Building over three stories
Q Demolition ❑Ot her: where the avai fable fault ci rent ❑ Mama and boelynrds
; crerEcou1r,'or,,togp*I)Ltoi 4'',,w 'r' ,:r exceeds 10 OM amps at 150 votq. or ❑ Rapture buildings
less to ground, or exceeds 14 000 ❑ Contractcial -use agneul I urnl
,..•2; I • and 2 - family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other Installations buildings
D Muni ❑ Master builder ❑ other. ❑ rota pump ❑ Wallin of 75 K VA or
❑F mcrgcncy system linger separately derived eyann
y
' 10B ,ff,E INNFORM.4TI!` 'I #Np 1,1 1'' 2 ' f,, �,0:'.!: In on of new motor load of
o m 100RIP mac, occupancy,
lob 0o' II O situ r / addrC55' ) N a A • ❑Six or more residential dolts ❑ Recreation al vehicle park
C. 7 tty /Blatt /ZIP y c) Q2 q - ,' ❑ Health-care facilities ❑ Supplwoltage for more than
_IJl' _
0 l lvudous Incnnona 600 wilts nominal
Suite /bldg./apt no I Project name, ❑ 5erssee or feeder 600 amps cr more
i'1'119it;S:I n,ril((r r( "PNvEI)'SC rilft',''; /'!
Cross street /directions to, job site Dmerlpaan ) 4tv,I Fre. I Thal' I
New residential single- nr multi - family dwelling unit.
Includes attached garage, I
Subdivision 1 Lot no.' _ 1 000 sq ft or less „ 145, h5 4 1
Ea add] 500 sq. H. or portion 33 40 I
Tux map /parcel no Limited energy residential
•
7500 2
''• 'nESCRVPTI64'or WOtJC." ' '' }.,,'1 : " ",'' /' (wish above, -ass al
n Limit ever v, mule -famd
'�/� / / ,V �/ Ito �� � residential with above :'4 R) 75 00 2
r L Services or feeders Installation• alteration, and /or relocatia
200 amps or less 1 8030 - 60, ' 02
CI: tC(PER.1V OWNER ' , (, , j '� IIyfECtiiiN'T,li;'!ir11:' '' [ (,p 201 amps to 400 amps 106.85 2
/� F72-7,7C-0/4 1 401 amps to 600 amps _
Name, C•a 1- 60 2
601 amps to 1,000 amps 24060 2
Address Over 1.000 amps or volts 454,65 2
City / Sidle /TIP' Temporary services or feeders installation, alteration, and /or it
relocation
Phone ( ) Fax ( ) 200 amps or less 66,85 I
Owner installation; This installation is being made on property that I own which is not 1 201 amps to 400 amps 100 30 I 2
intended for sale, lease rent, or exchange, according to ORS 447 449 670, and 701. 401 amps to 599 amps 133 75 I 12
Branch circuits - new, alterations or extension, per panel
Owner signature: Date; A Fee for branch crrmms soli
ClAPPLICANI Il I ' ' ∎OrCO V IA f d PE'IL5ON,I„ . P I;i,
. ,,. ' above service or feeder fcc, 6 65 2
1 ' ' each hunch circuit _
Business name. 42 A m r � did ( e B. Fee for branch circuits
-
�+ without service or IBeder foe. 46 85 2
Contact name' I ��u/ first branch circuit
Address: Each add I branch circuit I 6,05 2
Miscellaneous (service or feeder not included)
City /Statet7lt' Each manufactured or modular 90 2
dwelling, service and /or feeder
Phone. ( ) Fax • ( 1 Reconnect only
C 5 2
0 • V Pump or Irrigation circle 0 2
' ' , Io , CONTItACTOA -'. „i hl, u , , h, : l - ,. ,l ,u Islnihh.,;( Sign or outline lighting 5340 2
Business name. c,,'I 011AAQJ j e. � (j t 1��e, '
Signal culgs) or l imited•
-
energy panel alteration. or
Address, FO ey —1 extension Describe. Page 2 2
City /Slate /ZIP' 1.'- �� - k \ 5 h 'r OR r i 2 3 Each additional inspection over allowable in any of the above
( 66 , Per inspection 62 50
Phone' (�rp L!
3) L.I-t5 - 51 L.4.L -} I Fax ( 50'3) , 1 . - S - ‘ 7 I .7 3 . per hour I I hr min) 62.50
CC6 Lie `) $ I 1 9 VElectrical Lie 34_ C Sur Lie ' t 'e' '7 S f/ Industrial plant per hour j 71,45
1 . r ,r, , i ?Efterftt 'tt:PERNII aFEES;:' ( ;l�i;,� I i '.
Supry I`Icetncian stgrl lure- required Subtotal: ���
Plan review (25% of permit feel', • s
Print name. 1 l t/( A, S /°/ r t.%)/Ltre. Date:
Stain surcharge (12% of permit fcc),
Authorized signature, TOTAL PERMIT FFF Q 1
This permit application expires ifs permit a net ehiained w 0 1 0
Print noire I Date' aces afar It har linen , rrr■ted or romntnm