Permit ELECTRICAL PERMIT
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CITY OF TIGARD
PERMIT #: ELC2004 -00362
=
0 010 DEVELOPMENT SERVICES DATE ISSUED: 6/17/2004
12. 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
PARCEL: 23101 AB -01502
SITE ADDRESS: 07565 SW HERMOSO WAY
SUBDIVISION: HERMOSO PARK ZONING: MUE
BLOCK: LOT : 022 JURISDICTION: TIG
Project Description: 7 Branch circuits.
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL/PANEL:
MANF HM/ SVC/ FDR: 601 +amps - 1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: 6 IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
BRENT JACOBSEN CONTACT ELECTRIC & HARDWARE
4248 GALEWOOD ST 2517 E. EVERGREEN BLVD
LAKE OSWEGO, OR 97035 VANCOUVER, WA 98661
Phone: 503 - 892 -9301 Phone: 360- 694 -1512
Reg #: LIC 151628
ELE 37 -968C
FEES SUP 4929S
Description Date Amount
Required Inspections
[ELPRMT] ELC Permit 6/17/2004 $87.65
[TAX] 8% State Surcharge 6/17/2004 $7.02 Rough -in
Elect'I Final
Total $94.67
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 or 1 -800 -. • -2344.
Issued By 4 _i, � Permit Signature: .wA. ,
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 7:00pm for an inspection the next business day
Elf Permit Application FOROFFICE USE ONLY
Received 9 ,O 2
qty of Tigard Date/By: / I 7/01/ / PermitNo.: ' a� 7 36
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 A„,,,\ Date/By: Other Perm t:
Inspection Line: 503.639.4175 c a e` ' Date ReadyBy: is/. , El See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: I Supplemental Information
,,..,,,,.=14.;k. ��° a' .kr.'F"' , a�5 , •:;..t R�.�'z.E'd'�ii` =«a a .i =, + . s n. ° :.;. :�a•I wx•;�#, ;.a ` -"
1`?;��;• :; > � *�:..� � -a.a.a +..'�aia"?i�»^R. �- _,fr. <€� . -,�.- .".ter` .... ,�, ` �''.1"�� PT;AN _
El New construction lddition/alteration/replacement Please check all that apply:
1:1 Demolition El Other: ❑Service over 225 amps, comm'l ❑Hazardous location
❑ Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
s �i e( CATE af CONSTR CTI 'lY • " e , r 1 4 of I - and 2- family dwellings 4 or more new residential
:..:,.fi ".•, .:.. ., E , - i:,•&, xv +:,,t tsar.. ho..J...&& .�;. 4..,, - °a�. - 0,14, lii, ..�:.,..�:z . itvt '4
❑ 1 and 2 family dwelling ommercial/industrial ❑ Accessory building []System over 600 volts nominal units in one structure
CI Multi family El Master builder ❑ Building over three stories ❑ Feeders , 400 amps or more
❑ Ot her: ['Occupant load over 99 persons 5 Manufactured structures or
`l ' --' 3 103 z it FIFO TRIO gvi ATLOI - ' ,.-a,:. Egress /lighting plan RV, park
Job no.: 1 Job site address: - 7565 facility ['Other: - 7565 Ste, � - �e1111 OS Submit 2 sets of plans with any of the above.
City /State /ZIP: ( � The above are not applicable to temporary construction service.
�il f
Suite/bldg. /apt. no.: J Project name: I O r , G° . - •E a ' S CI3EDTJ ; LE �`�, : °`'t"�'.�'
jot Description 1 Qty. I Fee. I Total
Cross street/directions to job site: 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'1500 sq. ft: or portion 33.40 1
Limited energy, residential 75.00 2
Tax map /parcel no.:
.: :'. j r a:, ;•, w >: , w;�<, n ;, .. - ,. ,,, ... - . . ° ° , f Limited energy, non-residential 75.00 2
; D CRIP TION OF W OR D � ,' � �, a t ` i Each manufactured or modular
dwelling, service and /or feeder 90.90 2
Services or feeders installation, alteration, and /or relocation
200 amps or less 80.30 2
w;_'a v,a r 201 amps to 400 amps 106.85 2
s iaaft- r OW r5- " - ` :' ;', ,. � " `t •
.....,t .. f >r` TE1ANB •' P P
`" � 401 am s to 600 am s 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: / y Ai tP dirk ° 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: ( y�3j ggo� 9 �/ 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
""- ^., .. , �.i,�- �.?�:.:��'.�.;'s:��w- ,.Alrxi.;T '•�-= �,*�:�';,�:•:`. x ... < }w- ,;..y..��,4s.ss _uza�.•,a •s::j.�i:; ;-,
, ®�A1Videi NTV� W� V - A. Fee for branch circuits with
.. ..11 _.� „.; A .. _ . ;.. i s - �s &g-P ® CO ft,., T,,P R OiW r .
I service or feeder fee, each 6.65 2
Business name: Co j' e L + f / L . , g on L yArt - � ( branch circuit
Fee for branch circuits
TTT
Contact name: \, 9 V without service or feeder fee, l 46.85 2
Address: vt 7 , J each branch circuit ��
Each add'l branch circuit 6.65 Z�0,i0 2
City /State /ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle 53.40 2
Phone: ( ) l Fax: : ( )
Sign or outline lighting 53.40 2
E - mail: Signal circuit(s) or limited -
t > " ""o"" ter _ 7 energy panel, alteration, or
�,�, t.� • CONvTRAGTOR ..•. > :n- ,..
extension. Describe: Page 2 2
Business name: l ,( q
Address: as 4 `1 L E 11 er me ^ i�l j d Each additional inspection over allowable in any of the above
, n Per inspection 62.50
A V
City /State /ZIP: el co eo uer- t (,/,./ / -f / ? Investigation per hour (1 hr min) 62.50
Phone: ( f ) 6Qi e-(- 51 Z Fax ('6o) 6/61 - 66/ f) Industrial plant per hour 73.75
CCB Lie.: /./&2 Electrical Lic.: 7 --q6eisc Suprv. Lie.: ' 92..GLS Subtotal 97 I, 6
t D �
P lan review (25% of permit fee i
Suprv. Electrician signature, required: el� � � �� f ( p )
• 1, (Date: 7 � State surcharge % of pet fe Print name: uL �j C ,1 `
✓ TOTAL PER FEE q L�
Authorized signature: This permit application expires if a permit is not obtained ll within 18
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- PemntApp.doc 12/03 440- 4615T(10 /02/COM/WEB
r
Electrical Permit Application - City of Tigard `
Page 2 - Supplemental Information 1
LIMITED ENERGY PERMIT FEES:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
n 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:\Bu lding\Pemuts\ELC- PermitApp.doc 04/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Lice: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 - 4171 MST
BUP
Received Date Requested q- /O AM PM BUP
Location 7 H c5a Suite MEC
Contact Person pfrt/ Ph ( 360 ) °' 2 - 7 ( PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC 3,z.
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation 0
Drywall Nailing "�
Firewall
Fire Sprinkler
Fire Alarm _G FG I !z-CG -�
Susp'd Ceiling `S e-47 6X6��� 6-
Roof 2 fitr!/LE G{ /Lc u
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
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
larm
Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PART FAIL
E Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line l •
Approach /Sidewalk Date Inspector f �r E8EAA Ext
PP
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL