Permit t/
.. . ` Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 Planck/Rec. #
/ Al,.
�� I Permit # �=- 1 ---C ' - t� `{/ z
A iI _ Phone (503) 639 -4171 Date Issued
t ^�' FAX (503) 684 -7297
CITY OF TIGARD TDD No. (503) 684 -2772 Issued by
Inspection (503) 639 -4175
1. Job Address: , r 4. Complete Fee Schedule Below:
Name of Development /1QL Number of Inspections per permit allowed
Address /0 3 - y) n S, C1 9, pc 4-e Le S Service included: Items Cost(ea) Sum
City /State/Zip `T /, A-2 ( /2 97 2, Z 4a. Residential - per unit 4
1000 sq. ft. or less $110.00
Name (or name of business) grit- -/ A7/1)01-6 Each additional 500 sq. ft: or 1
portion thereof $25.00
-
Commercial ❑ Residential. Limited Energy $25.00
Each Manuf'd Home or Modular 2
Dwelling Service or Feeder $68.00
2a. Contractor installation only: 4b. Services or Feeders
F: Installation, alteration, or relocation 2
T
Electrical Contractor /1/1 Le - '7t C. 200 amps or less $60.00 2
Address 5.'9D c, a, . 2An-fA l ,k ii,,„•r g- i 0.5 201 amps to 400 amps $80.00 2
City 7 Zip CI �c ) �i2 D State ZI 7 �� 401 amps to 600 amps $120.00 601 amps to 1000 amps 2
$180.00
Phone No. ( ; - h bk I Over 1000 amps or volts $340.00 2
Contractor's License No. 31/ - Igo Reconnect only $50.00
Contractor's Board Reg. No. 40 ?. 3 2 4c. Temporary Services or Feeders
Installation, alteration, or relocation 2
Signature of Supr. Elec'n 200 amps or less $50.00 2
License No. /` -`� Phone No. b37 66,67 201 amps to 400 amps $75.00
401 amps to 600 amps $100.00
Over 600 amps to 1000 volts
2b. For owner installations:. see - b• above.
4d. Branch Circuits
Print Owner's Name New, alteration or extension per panel
Address a) The tee for branch circuits with
City State Zip purchase of service or feeder fee. 2
ty p Each branch circuit $5.00
Phone No. b) The fee for branch circuits without
The installation is being made on property I own which is purchase of service or feeder fee. 1 2
Each 2
not intended for sale, lease or rent. East brddch circbit 1 $$5.00
ch additional branch circuit niv-- $5.00 '
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or irrigation cirde $40.00 2
Each sign or outline lighting $40.00
Signal circuit(s) or a limited energy 2
Please check appropriate item and enter fee in section 5B. panel, alteration or extension $40.00
4 or more residential units in one structure Minor Labels (10) $100.00
Service and feeder 225 amps or more
System over 600 volts nominal 4f. Each additional inspection over
Classified area or structure containing special occupancy the allowable in any of the above
as described in N.E.C. Chapter 5 Per ins $35.00
Per hour $55.00
-
In Plant $55.00
Submit 2 sets of plans with application where any of the above
apply. Not required for temporary construction services. 5. Fees:
5a. Enter total of above fees $
NOTICE `3J / , ��
5% Surcharge (.05 X total fees) $ =--��'
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $ �Jf""�-
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF Sb. Enter 25% of line A for `
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Review if required (Sec.3) $
A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal $
COMMENCED. ❑ Trust Account # $
Balance Due $ .....Y...6.1--r
wad t ( c-_ � .1 q/
3/30/00 Activities for Case #: ELC95 -00412
4:53:30 PM
Assigned Hold Updated
Activity Description Date 1 Date 2 Date 3 To Done By Disp. Level By U pdated N otes
ELCA001 Application received 9/25/95 JIM RECD TMP 11/29/95
ELCA003 Permit created 9/25/95 JIM RECD TMP 11/29/95
ELCA500 (F) Issue permit 9/25/95 JIM PASS TMP 11/29/95
ELCA799 Elect'I Final 12/4/95 MJR PASS - MJR 12/4/95 hot tube
ELCA800 Case finaled 12/4/95 MJR YES MJR 12/5/95
•
•
•
•
Page 1 of 1