Permit CITY OF TIGARD ELECTRICAL PERMIT
2 ' 7 COMMUNITY DEVELOPMENT Permit #: ELC2009 -00376
T I GARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/27/2009
Parcel: 1 S134CA03400
Jurisdiction: Tigard
Site address: 11860 SW NORTH DAKOTA ST
Subdivision: Lot: 0
Project: Woodworth
Project Description: Install new groundig system and rewire disposal, (2) circuits affected.
Owner: FEES
WOODWORTH, JILL CRAWFORD Quantity Description Date Amount
PO BOX 6057
ALOHA, OR 97007 2 crt Branch Circuits 07/27/2009 $53.50
wo /Purchase Service or
PHONE: Feeder
1 ea 12% State Surcharge - 07/27/2009 $6.42
Electrical
Contractor:
BENTLEY ELECTRIC INC
41330 SW EDNA LANE
GASTON, OR 97229 -9625
PHONE: 503 - 985 -9500
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $59.92
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 issu nce, 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 enter. Those ru are set forth in OAR
952 - 001 -0010 through AR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.24 699 or 1.8 .332.2
Issued By: d\ot 1.I L1 N IQ t/1 ^ 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 an Inspection that business day.
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.
Llectriical Permit Application RECEIVE] FOR OFFICE USE O LY
• eceive P ermit N o.: 1 • V j
City of Tigard DateB : s I bi I (3G
I I 13125 SW Hall Blvd., Tigard, OR 97223 ti 2 7 2 009 009 Plan Review
. Phone: 503.639.4171 Fax: 503.598.1960 JUL Date/By: Other Permit:
f 1 C; A R D Inspection Line: 503.639.4175 Date Ready/By: Juris: ID See Page 2 for
Internet: www.tigard - or.gov CITY OF TIGARD Notified/Method: T Supplemental Information
TYPE OF WOR8UIWDING DIVISION PLAN REVIEW
❑ New construction Addition /alteration /replacement Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition Other: where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION • exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
ig
I - and 2- family dwelling 0 Commercial/industrial 0 Accessory building amps for all other installations. buildings.
Multi- family 0 Master builder 0 Other: 0 pump. ❑Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "1 -3 ",
Job no.: I Job site address: I ( (DO 4 l 100HP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: — 11 &AL° 2 �3 b44001 T ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE ,
Cross street/directions to job site: Description I Qty, I Fee. I Toot I •
• New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4
Tax map /parcel no.: Ea. add'I 500 sq. ft. or portion 33.40 I
Limited energy, residential 75.00 2
DESCRIPTION OF WORK , . . (with above sq. ft.)
tJlt,I W L iA ` f r L E (t! n y �� Limited energy, multi-family
s .lf 75.00 2
tit a.n, w,J £ � residential (with ab ov e sq. ft.)
T p 05 4 c �1 � 'r .e Services or feeders installation, alteration, and/or relocation
�/(5 f �t i-C 200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: , ( (1, (4 001) WO XN 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: pp 60v X17 Over 1,000 amps or volts I 454.65 12
City /State /ZIP: &CD OA- CA— c'7j ` Temporary services or feeders installation, alteration, and /or
relocation
Phone: (5 (, 3'° it IT I Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. _ 401 amps to 599 amps 133.75 2
Branch circuits- new, alteration, or extension, er panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 6.65 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, I 46.85 2
first branch circuit
Address: Each add'l branch circuit I 6.65 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular '
dwelling, service and /or feeder 90.90 2
Phone: ( ) Fax: : ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name: 0 g,J {LEI f t ntVC. Signal circuit(s) or limited -
, A r energy panel, alteration, or
Address: (4 13 30 S� E,jI14 L extension. Describe: Page 2 2
City/State /ZIP: CiASM\/ 4771 l 4 _ Each additional inspection over allowable in any of the above
p Qq Per inspection 62.50
Phone: (5'03 / %Q —cj u ( I Fax: (56) -L O 5 - q5 1 75 - Investigation per hour (1 hr min) 62.50
CCB Lic.: v v I Electrical Lic. qqq I Suprv. Lic.: _Industrial plant per hour 73.75
�_ 1 (p ELECTRICAL PERMIT FEES
Suprv. Electrician sign required: J ,.
RG„�.� l O l t o Subtotal:
Print name: j &, Qd��� Date: -
Plan review (25% of permit fee):
State surcharge (12% of permit fee):
-
Authorized signature: TOTAL PERMIT FEE: Z9 , q 2
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\Building\Permits\ELC- PermitApp.doc 05/23/06 440- 4615T(II/05 /COM/WEB
Electrical Permit Application - City of Tigard f -
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systems*
n Other:
• COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000)
• Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
•
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
I: \ Building \Permils\ELC- PermitApp.doc 03/23/06