Permit Electrical Permit Application ' Foli OFFICE USEONLY
City of Tigard . Received 0 -7 �r/ ' � S �0 ,.
-_. . : Permit No. `, 7 ,
13125 SW Hall Blvd., Tigard, I * , _.
i Date /B r 3 ��® Plan Review
Phone: 503.639.4171 Fax: 503. ' ..I' .0 Ge� »�:Aw,r(�r '' I'`f Date/B . Other Permit:
Inspecti Line: 503.639.4175 IX' uI_' , Date Ready/By: Juris: ® See Page 2 for
Internet: www.ci.tigard.or.us SEP 2 3 2005 Notified/Method: Supplemental Information
T YPE OF WORK PLAN ,REVIEW ' . -
New construction G Y QFit T o ton/replacement Please check all that apply:
BU� (5 D N 0 Service over 225 amps, comm'I 0 Hazardous location
❑Demolition LLJJ Other:
❑ Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
. CATEGORY OF CONSTRUCTION . of 1 -and 2- family dwellings 4 or more new residential
N 1_ and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi- family ❑Master builder ❑Other: ❑Building over three stories ❑Feeders, 400 amps or more
❑Occupant load over 99 persons ❑Manufactured structures or
JOLSITE INFORMATION AND LOCATION , ❑Egress /lighting plan RV park
Job no.: 35 6,� Job 0 site address: 3 ) Q I S � UR Z f ��grl'� Health -care facility ❑Other: \
• r bmit 2 sets of plans with any of the above.
City /State /ZIP: !/
, Oe - G - 2 273 3 The above are not applicable to temporary construction service.
Suite /bldg. /apt. no.: / �/ Project name: , / / J � ��� FEE* SCHEDULE
nl jN Mein .5 >;3g"CSU�l fy . Description I Qty. I Fee. Total I **
Cross street/directions to job site: Pn 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 1
SUM 1 f I Limited energy, residential 75.00 2
Tax map /parcel no.: Limited energy, non - residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
l l I 6(14/.% _ dwelling, service and/or feeder 90.90 2
j(/f)N 4 l_I.s' /4P' Services or feeders installation, alteration, and /or relocation
• 200 amps or less 80.30 2
201 amps to 400 amps 106.85 2
PROPERTY OWNER I ❑TENANT 401 amps to 600 amps 160.60 2
Name: ' _ .d .. - �� 601 amps to 1,000 amps 240.60 2
Address: YZ3 t - 4 . tJt))2 ,6/W- � 5 ✓1 , _ /GO Over 1,000 amps or volts 454.65 2
/ Reconnect only 66.85 2
City /State/ZIP: J_.A,K T 65 to - - �, 1-763 5 Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( 5 3) 3 $7 _ ''2 3 E--- I Fax: (5 0 3 ) 36? ?..._ 7 l,s- 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
0. APPLICANT ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee, 46.85 2
Address: each branch circuit
Each add'I branch circuit 6.65 2
City /State /ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle . 53.40 . 2
Phone: ( ) I Fax:: ( )
Sign or outline lighting 53.40 2
E -mail: Signal circuit(s) or limited-
' CONTRACTOR energy panel, alteration, or
f � extension. Describe: Page 2 2
Business name: U ri G Etz. z„ E c Liz- ,
• 2334 f / a Each additional inspection over allowable in any of the above
Address: i . _ i' ,�._:..� _ `� a te , -
Per inspection 62.50
City /State/ZIP: je t n ,,, 14 W ` c #C '0'75 G Investigation per hour (1 hr min) 62.50
Phone: ( 3) .- 35-7 / Q 2 p' I Fax: (5-43) � "?3 c� z/ if � Industrial plant per hour 73.75
v lB o ELECTRICAL .PERMIT ' FEES
CCB Lic.: / 3 ? ? '7? Electrical Lic.:3 y p3 I Sup v. Lie.: 33 5 Subtotal
. Suprv. Electrician signature, required: Plan review (25 %ofpermit fee)
1 ---
State surcharge (8% of permit fee)
Print name: 91.02- 4d Date: ei 31 -
�� �'�) / L TOTAL PERMIT FEE
Authorized signature: T his 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
•• Number of inspections per permit allowed.
i:\ Building \Permits\ELC- PemtitApp.doc 12/03 440- 4615T( 1 0 /02/COM/WEB
Electrical Permit Application - City of Tigard
Page 2.- Supplemental Information
LIMITED ENERGY PERMIT FEES:
r RESIDENTIAL 'WORK ONLY: ty
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:
COMMERCIAL WORK ONLY:
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- PermitApp.doc 04/03