Permit it:
f;hWASHINGTON COUNTY ELECTRICAL PERMIT
s 7113efitittmenrof Land Use & Transportation ',``
,-
155 N orth First Av enue, ical h is n Avenue, #350 -12 A P P L I CAT I ®IV ' ?ii
155 N Av
Hillsboro, Oregon 97124
ation: (503) 6404470 Fax: (503) 693 -4412 a
Permit '�
'LEASE PRINT Number -�i �� e �() Date C� - 75
; Please complete all sections, 1 through.5 4. Complete Fee Schedule below y
g i
Number of inspections per permit allowed ; '
1. Location of installatio
Address 1 2`i ( c 1 5 < 'J 0 t_ i.- D IZ . Service included: Items Cost(ea.) Sum
Building A. Residential - per unit i 1.
J
Cit t t �. Ng7 Suite No. 4 i , r
1000 sq. ft. or less i d '.110.00 4 .,
Tenant Name Each additional 500 sq. ft ° f
(d commercial) or portion thereof $25.00
Limited Energy $25.00 1
Map No. Tax Lot Each Manuf'd Home or Modular
Dwelling Service or Feeder $68.00 2
Thomas Map Book: Page: Section: ,4
Directions. B. Services or Feeders t
Installation, alterations or relocation '
200 amps or less $60.00 2 z
Commercial ❑ • Residential PIZ 201 amps to 400 amps $80.00 2 -
401 amps to 600 amps $120.00 2
601 amps to 1000 amps $180.00 2
2a. Contractor installation only: Y Over 1000 amps or volts $340.00 2
Electrical Contractor Reconnect only -IZ- $50.00 )`_d 2 . ;
Address
City State ZIP C. Temporary Services or Feeders
Date Job Number Installation, alteration or relocation
Property Owner K o R-T K 05 it 200 amps or less $50.00 2 '11
Contractor's License No. 201 amps to 400 amps $75.00 2
Contractor's Board Reg. No. 401 amps to 600 amps $100.00 2
g Over 600 amps to 1000 volts see 'B' above
Signature of Supr. Elec'n D. Branch Circuits
License No. Phone No. New, alteration or extension per panel .o
a) The fee for branch circuits with -`
2b, n er r owner installations: purchase of service or feeder fee.
( 4 C . K � `d4A / _ . y -c c , 1 C Each branch circuit $5.00 2
Print s ame {' � P ? hone No. G [ 1 b ) The fee for branch circuits w
5 1 D �� s fA f) ' b 'S -- purchase of service or feeder fee. i.
Address First branch circuit $35.00 2 '
rfj I �DIs^ 1 � (40 o ( 1, Z I Each add'nl branch circuit $5.00 2 s> F ':
City state Zip E. Miscellaneous (Service or Feeder not included
Each pump or irrigation circle $40.00 • 2 ,ix:
The installation i - be ng made on property I own Each sign or outline lighting $40.00 2 + `'
leas Signal circuit(s) or a limited 'I
which is not int= d - • • r S , = �-, r ent.
"A'N energy panel, alteration
Owner's Signature � r
F. Each additional inspection over the allowable
in any of the above '
3. Plan Review section (if required) Per inspection $35.00 •
Per hour $55,00
Please check appropriate Rem and enter fee In section 5B. In Plant $55.00
4 or more residential units in one structure 5. Fees
Service and feeder,. 800 amps or more
System over 600 volts nominal ":.. A. Enter total of above fees $ - •
Classified area or structure containing special %:: 5 °�6 Surchargf (.05 X total fees $ • • 2•, - - - ''
z $ =� fi `
o as described in N E.0 Chapter 5 - Subtotal -' 3 w .( , _ �° ; z -- , , - m ,1, r
4 _ _ rS1� f ., �. �. .�f z � _ � B. Enter 25% of line A for , " "�. r
Z,L':. , -c t - - r.. i-s 4 0
, �."x z , ',- c" W;. -.; F^r is r�-. • ,.. u.v. _ _ ,sc •a ��`,ia : %;; : 5 4.4 - ' y ' n � > d'r"3
e ts ' of � l ans with. a' application "where any of the ;:k -,, f3 ,, ; v Pl a n 4 Re vi e w rf re ct
(Sei $ - ; y
Submit 2 } s P PP Y - •.,.: .. .,r . �, �. ,,� • on 3) � �� •
v l _ Not re q uired`for tem p ora co nstruction A , . ; .,.5 •Subtota ;' ' r -, ` "t : $ R - .4
abo a aPP Y� r.� q...� "� P. rY . . t�. •; �, '� �� :�-- ��;��y ; ' -
¢ S 1"kz"�, , : okir4 �,7t -s � -t ,k ' .s.i.....,R4 `^.'� ••-'ti;• $ ' .i_, • &fir * *;
.,5
..:e A-;. ®Trust- i4ccount•� ,
8ervlCes. �r xt'tR F4' w 1 l u r, n r a � ' :. 4: tE ro. 4 D 3 5X 4 -M
6 S
nce, - ,. , ' - ?')> ��
e - " -4.- Fo i cal z � - ; - { ` . a , Bala , ,, . :' :. $ - ,- .
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; w . , . r . ^ . 7, - f pm ." ' maned � �,�. ,
, ,, � - ; ; � � : �, :�: , �` - .'� ;�;��,.,,� * 4.�. - v t w.Th k becomes null and void 11 the work authorized the M b not oom Y%^atie��•- r ;„
.. . • ' ' - • within 180 days from data of issuance of such permit or if the work authorized is . 4`,'+ A:'- L7; r •,p i
6 4 0 = 3 o r , 69 3 = suspended or abandoned at any time after work is commenced fora period of 180 days.
24 -hour recorder; one working day in advance of need Electrical Permits am non - refundable and non-transferable. a
< 8/94 - �' y F
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