Permit CITY OF TIGARD ELECTRICAL PERMIT
- COMMUNITY DEVELOPMENT Permit #: ELC2012 -00091
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/08/2012
Parcel: 2S102CB02300
Jurisdiction: Tigard
Site address: 13240 SW PACIFIC HWY
Project: Pacific Medical Group Subdivision: FREWING'S ORCHARD TRACTS Lot: 8
Project Description: (1) branch circuit to reconnect RTU.
Contractor: PRO CIRCUIT ELECTRIC LLC Owner: TIGARD MEDICAL CENTER
PO BOX 3948 13200 SW PACIFIC HWY
WILSONVILLE, OR 97070 TIGARD, OR 97223
PHONE: 971 - 563 -8211 PHONE:
FAX: 503 - 266 -1349
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 02/08/2012 $56.18
Specifics: Service or Feeder
1 ea 12% State Surcharge - 02/08/2012 $6.74
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 co y of the r irect questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: i , i Permittee 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.
Electrical Perini t Application FOR OFFICE E;SE ON •
C
•
ity of T;i E;ard Received 13125 SW Hall blvd., Tigard OR 9 � E Da( e!B J� Permit No.:
Phone: 503.63;44171 Fax: 503.59 .1960 Plan Review
TIGARD lnspectionl.iuc 503.639.4175 FEB $ 2.0‘2.
Date/By: Other Permit:
Internet. www Tigard -or.gov Date Ready/By: r°ris, I
S
r Notified/Method: � E ! upptcmcnral Se t formation
— -rrn 1�, 3
TYPE OF wo{ 7if Or 1 to :. .
Or_ ^rk "l1«')D.� PLAN REVIEW
O New construction Add ition/ alterafitnVailla Please check all that apply (submit 2 eels of plans w /items checked below): ❑ Other:
❑ Service or feeder400 amps or more 0 Building over three stories.
what the available fault current 0 Marinas and boatyards.
CATEGORY OF CON STRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ I- and 2- family dwelling Comtnercialrndustrial ❑ Accessory building less to ground. or exceeds 14.000 12 Commercial -use agricultural
a all other installations buildings.
❑ Multi - family
❑ Master builder. ❑ Other: ❑ Ffire re pump.
JOB S1TE INFORMATION AND LOCATION ❑ l a gerse p arat �SKVpor
0 Emergency system. larger separately derived system.
(3��0 ❑Additionofpewmotorload ❑ "A ",'1 ° t - 2 "'I - 3"
J Jo a site address. I Rug e/ 10oHPeemore.
Pl�(, yc _ n W J occupancy.
lob no.:
City /Statc/ZIP: -r; G. ❑Six or more units. ❑Eecrrational vehicle parts,
❑ Health -pre facilities. ❑ Supply voltage for more than
Suite /bldg /apt, no.: Project name: a ❑ Hazardous locations, 60D volts nominal.
le II : ° � r ❑ Service or feeder 600 amps or mono.
Cross street/directions to job . ;ite: FEE SCHEDULE
_ Description 1 Qty. I Fee I Torsi I •
New residential single- or multi-family dwelling unit.
Subdivision: Inctudes attached garage.
Lot no.: I,000 sq. ft. or less 168.54 4
Tax map /parcel no.: Ea. add'I 500 sq. fI or portion
33.92 I
DESCRIPTION OF WORK Limited energy, residential
with above , .11. 67.84 2
C �5 Q &t fl ! /L 4 n Limited energy, multi- family
ll /V I"1(7�^ residential {with above sq- IL) 67.84 2
Services or feeders installation, alteration, and/or relocation
❑ PROP ( E 1 RTI( OWNER y ENS I , 200 amps or less I 100.70 2
Name: n 04C•t r r ... D 1 �� - �" • 201 amps to 400 amps J 133.56 2
C lF 401 amps to 600 amps 200.34 Z
Address: 601 amps to 1,000 amps 301.04 2
City/S 2
ZIP: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
Phone: ( ) relocation
Fax: ( ) 200 amps or less
Owner installation: This ins'.a I lotion is being made on property that I own which is not amps to 400 amps 59 6 I
intended for sale, lease, rent, Cr exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 1 25.08 2
Owner signature: 16854 2
Date: Branch circuits- new, alteration, or extension, per panel
1:3 APPLICANT' A. Fee for branch circuits with
1 ❑ CONTACT PERSON above service or feeder fee,
Business name: each branch circuit 7 -42 2
Contact name: B. Fee for branch circuits
without service or feeder fee,
first branch circuit
Address: ( 56.18 I 2
Each add'I branch circuit 7A2 2
City /S4 1tc /ZIP: Miscellaneous (service or feeder not included)
Each manufactured or modular - 1
Phone: ( )
dwelling, service and/or feeder 2
fias:: ( )
E -mail: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84
2
Business name: (� - � - - Sign or outline lighting
t-! _�0 I c { JT ( l "� Signal circuil(s) or limited- G7 - 2
Address: o �t� t '# r energy panel, alteration, or • t extension. Describe: Page 2 2
City /State/ZIP: ���.5 ® r;' f
O`7 0 Each additional inspection over allowable in an of the above
5�3 , p - , 7 .,, Fax: ( e J ~ b '� ) z �� t� /C � Per inspection 66.25
Phone: ate/ (T?( )
[ 't Investigation per hour (I lir min) 66.25
j Electrical Lic.: - c a b( ` Suprv. Lie.: � 1 �� 5 I plant per hour
Suprv. Electrician signature, required: I 78.18 -.
ELECTRICAL PERMIT FEES
Print name: "A ) �t Date: Subtotal: 11,11.11
O ._.2z— s Plan review of permit fee):
Authorized signature: -
Print name:
State surcharge (12% of permit fee):
TOTAL PERMIT FEE: �
1 rw
Date: This permit application expires ifs permit is not obtained within ISO
days after it has been accepted as complete
1. 1Doildioslpv ,oitstELC ren„irnpa.doc tororrc i
• Number of inspections allowed per permit.
44 0-4sisrturosrcosvwsa
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