Permit '` Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 P lanck/Rec. # 9 f- P. 7/9 ? C
# 4111° ...�8 ,, Permit # Eirqc =hy7'
, i Phone (503) 639 -4171 Date Issued io - ao - 95
FAX (503) 684 -7297
Issued by C
CITY OF TIGARD TDD No. (503) 684 -2772 lia� /� r Se Ain ��,,/�
Inspection (503) 639 -4175
1. Job Address: 4. Complete Fee Schedule Below:
I Name of Development ((A5 e k/i t Number of Inspections per permit allowed
Address /3907D SO) L4f1 eM D 4 . Service included: Items Cost(ea) Sum
City /State/Zip - T Y9 9 A,ryl__ DA q767-.9.3 4a. Residential - per unit / 4
�/�/� 1000 sq. ft. or less / $110.00 fie.
Name (or name of business) 1 L Each additional 500 sq. ft. or $25.00 /Op I ii portion thereof
Commercial ❑ Residential PI 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
1 Installation, alteration, or relocation 2
Electrical C ntr / 200 amps or less $60.00 2
Address /D i m b .- . 201 amps to 400 amps $80.00 2
401 amps to 600 amps $120.00
City 13 1 Jn r to el State /)K . Zip 9 zin8 601 amps to 1000 amps $180.00 2 -
Phone No. [o // Z Over 1000 amps or volts $340.00 2
Contractor's License No. e?!n- 2439C Reconnect only $50.00 -
Contractor's Board Reg. No. --ii .P-- 4c. Temporary Services or Feeders
r Installation, alteration, or relocation 2
Signature of Supr. Ele ' 200 amps or less $50.00 2 - 201 amps to 400 amps $75.00 2
License No. 3'. 9 A 4 .1 Phone No. (04/ -f )/ 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 fee for branch circuits with
City State Zip purchase of service or feeder tee. 2
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. 2
First branch circuit $35.00 2
not intended for sale, lease or rent. Each additional branch circuit $5.00
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or irrigation circle $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 inspecti $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: �/�
NOTICE 5a. Enter total of above fees $ I C : C)C
5% Surcharge (.05 X total fees) $ sr)
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $
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 $ p® 56
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