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Permit CITY OF TIGARD ELECTRICAL PERMIT 11 91 7 . COMMUNITY DEVELOPMENT Permit #: ELC2012 -00070 TfGAR.D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01(31(2012 Parcel: 1S136DD06900 Jurisdiction: Tigard Site address: 11875 SW 69TH AVE Project: Roth Subdivision: WEST PORTLAND HEIGHTS Lot: 5 -8 Project Description: Rewire house due to fire damage. Contractor: GRIZZLY ELECTRIC Owner: ROTH, J T JR & THERESA A 8002 NE HWY. 99 PMB #248 12600 SW 72ND AVE, STE 200 VANCOUVER, WA 9865 TIGARD, OR 97223 PHONE: 360- 909 -4080 PHONE: FAX: 360 - 694 -8939 FEES Quantity Description Date Amount 14 crt Branch Circuits wo /Purchase 01/31/2012 $152.64 Specifics: Service or Feeder 1 ea 12% State Surcharge - 01/31/2012 $18.32 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $170.96 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. 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 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 OAR 952- 001 -0090. You may obtain a .. • • - les or • = - • estions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Perm ittee 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' Date: LICENSE NO. _ Call 503.639.4175 by 7:00 a.m. for the next available inspection date. 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. Grizzly Bea 360 -694 -0939 p.2 Electrical Permit Application FOR OPhI('F. USE O \1:1' City Of Tigatrd %\11" Received 7/ Permit No.: I" 1 ., 0 /t i III c l7ateBv: ❑ 1. ilr ' // 6 1 / f07110 ° 13125 SW Ball Blvd., Tigard, 0 p Plan Review I Phone: 503.718.2439 Fax: 503. i8. 960 tt��� r el t_ +ate, B : C CI o Other Permit: II Il [ I r C 1 "r I t i A It I' Inspection Line: 503.639.4175 Y` \ \� l Bate Ready/By: I)Oi 111: luny: ® See Page z for Internet: www.tigard- or,gov t O� ,o,**-' • Notified/Method: 0 £0 3t Supplemental Information TYPE OF WORK \\ ` , \\ Print name: :11.1171:1 _ - 1 L y ct U New construction LdcAddition /alteration/Iepieement PLAN REVIEW ❑ Demolition ❑ Other: 00000 \'y Please check all that apply (submit 2 sets of plans writems checked below)' CATEGORY OF CONSTRUCTION ❑Service or feeder 400 amps or more ❑ Building over three X.4- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building where the available fault current stories. ❑ Multi- family ❑ Master builder ❑ Other: ❑ ❑ ❑ ❑ ❑ exceeds 10,000 amps at 150 volts or ❑ Marinas and boatyards. JOB SITE INFORMATION AND LOCATION less to ground, or exceeds 14,000 amps for all other installations. ❑ Floating building. OF Job lira ❑ ommercial - use 3obno.: ❑ ❑ ❑ ❑D lob site address: 000❑0�/ 75" 5.6t) _� l p' agricultural ❑ Emergency system. buildings. City /State /ZIP: 0 0 0 00 7 f ©,� El Addition of new motor load of ❑ Installation of 75 KVA Suite/bld /a t. no.: ❑ 0 0 ❑ 0 larger separately derived system. II Project name: 0 0 0 ❑ ❑ ❑ 100 or more. or g• P 1 Six or more residential units. Cross street/directions to job site: 0 0 0 0 0 ❑ Health facilities. ❑ occupancy. ❑ Hazardous locations. 00000 ❑ Recreational "chicle ❑ Service or feeder 600 parks. Subdivision: 0 0 0 0 0 I Lot no.: 00000 amps or more. ❑ Supply voltage for Tax map /parcel no.: 0 0 ❑ 0 ❑ more than . 600 volts nominal. DESCRIPTION OF WORK 00000 " te- G1 t9 ts- gDvsfe *41 had FEE SCHEDULE DescriViion I Qty1 Fee. I Total I. 00000 t 'r ev 0owe19� New residential single- or multi - family dwelling unit. / Includes attached garage. ❑ PROPERTY OWNER I ❑ TENANT 1,000 sq. ft. or less IP 168.54 , \f:\.,�'. Name: 00000 Ea. add'l500 sq. ft, orportion ICI 33.92 11I I1:1I.; 1 Limited energy, residential 75.00 DLIIIILThl 2 Address: 0 ❑ 0 0 0 (with above sq. ft.) Limited energy, multi- family 75.00 l L1 J f. 2 11 1 City /State /ZIP: 0 0 0 0 ❑ residential (with above sq. tt. ) Services or feeders installation, alteration, and /or relocation Phone: (ODD 00)0000LI Fax: (00000)00ODD 200 amps or less •o 100.70 i;;lrlli. 2 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps l r I 133.56 i1;11 2 intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 111.1 200.34 I : I (. I:I I ; 2 Owner signature: Date: 601 amps to 1,000 amps ❑ u 301.04 I ".11:1 r1 I : 2 ❑ APPLICANT I ❑ CONTACT PERSON Over 1,000 amps or volts III 552.26 l' 111111 2 Temporary services or feeders installation, alteration, and /or Business name: ❑ 0 0 0 0 relocation 200 amps or Itss I 11 59.36 1.11] I I..I LI 1 Contact name: 0 0 0 0 ❑ 201 amps to 400 amps III. 125.08 111 11 1.11 1 2 Address: 000 ❑ ❑ 401 amps to 599 amps LH_ 168.54 1 1.111 2 Branch circuits - new, alteration, or extension, per panel City /State /ZIP: 0 00 0 0 A. Fee for branch circuits with above service or feeder fee, l 11. 7 42 1" " l n'i in 2 Phone:(00❑ ❑0)00000 Fax: :( ❑0000)000❑❑ each branch circuit E-mail: ❑ ❑ ❑ ❑ ❑ B. Fee for branch circuits without r service or feeder fee. first I1I 1 56 18 .' J I� J 1.' 2 CONTRACTOR branch circuit' Business name: 0 0 0 0 0 rite.- t�IG __I--/VC. F�c cella branch circuit 7.42 111 2 Miscellaneous (se or feeder not included) Address: 0 0000 v / vE At 9 n 101 Each manufactured nr modular II. 67.84 U 2 ■ �� �/ �y /► dwelling, service and/or feeder City /State /ZIP: ❑ ❑ ❑ 0 ❑ ��' �.,�, t.4.0/4k % 8 .0 - Reconnect only in I 67.84 1 11.11 111 I 1 2 ( J,. ) A I ( ,. y /• _ ) p ^ , t y � �� Pump or irrigating L crcle l ii ir 67.84 1111111.111 2 Phone: ❑ � � l ( F 1 T / / 1 Fax: f 4 ' r L L V A [ 9 ❑ f7Ty/AF611 Sign o r irrigation lighting 1 u 67.84 n 1.1 u u 11 2 CCB Lic.: [11 1:,60.1 V Electrical Lib zf _ _ „ (,-I Suprv. Lie.: 211 J ■ S Signal circuit(s) or limited - energy III • fin I I I V panel, alteration, or extension. Page 2 2 Suprv. Electrician signature, required: �� Each additional inspection over allowable in am of the above Additional inspection (1 hr min) 111 66.25/ hr I ] L. i "1 Print name: 71 Date i r r•�,! 1.1 .v • 1 �© 7.r L::1I ! I Investigation (1 hr min) .30 66.251 hr Authorized signature: I - Industrial plant (I hr min) ! I.I 78.18 / hr 1 II I' 11tniI4ing \Penrita\ELC- PennitApp.doc 07/01/10 440-46151(11/05/COM/WE6 Lti 76 (- 56. ,