Permit CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
3 • COMMUNITY DEVELOPMENT Permit #: ELR2012 -00066
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/11/2012
Parcel: 25111 CD01200
Jurisdiction: Tigard
Site address: 9500 SW SUMMERFIELD DR
Project: Miller Subdivision: SUMMERFIELD NO.7 Lot: 362
Project Description: Install video and network distribution panel in garage.
Contractor: OWNER Owner: MILLER, SCOTT
9500 SW SUMMERFIELD DRIVE
TIGARD, OR 97224
PHONE: PHONE: 503 - 560 -2951
FAX:
FEES
Description Date Amount
Specifics: Restricted Energy Permit 04 /11/2012 $75.00
12% State Surcharge - Electrical 04/11/2012 $9.00
Type of Use: SF
Class of Work: ALT
Total Number of Systems:
Audio & Stereo: N
Security Alarm: N
Garage Door Opener: N
HVAC: N
Vacuum System: N
Other: N
Other Desc: Total $84.00
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 ccorda .'th 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. TTENTION: Oregon aw .u= you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 01 -0010 through OAR 952-1s -0090. o , y obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Is u By: Permittee Signature: .1.-j f ' Mat
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.
Thls 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 Permit Application FOR OFFICE USE ONLY
City of Tigard Receive / Per mit No.:
e H �� /� o /�— tt.la0
• 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C . Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:
T 1 G AR D Inspection Line: 503.639 Date Ready /By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK 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
® 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "I -2", "1 -3 ",
Job no.: Job site address: 9500 SW Summerfield Dr IOOHP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: 97224 ❑ Health-care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: video , network panel )-1 (tti/L ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Summerfield Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 I
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
- Limited energy, multi - family 75.00 2
Install video and network distribution panel in garage and run to 6 locations residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
in structure 200 amps or less 100.70 2
® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: Scott Miller 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: 9500 SW Summerfield Dr Over 1,000 amps or volts 552.26 2
City/State/ZIP: Tigard, OR 97224 Temporary services or feeders installation, alteration, and /or
Y g relocation
Phone: (503)560 -2951 cell Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale, lease, re t, or exchange, according to ORS 447, 449, 670, and 701.
�p Branch circuits — new, alteration, or extension, per panel
Owner signature: Q L ��� ��Z� ^m-{�l Date: T -1 /' /) A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: R. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City/State/ZIP: Each manufactured or modular 67.84 2
tY dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: i'C.Jre panel, alteration, or extension. x Page 2 I
( � 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (I hr min) 66.25/ hr
Investigation (1 hr min) 66.25/ hr
City/State /ZIP: Industrial plant (I hr min) 78.18/ hr
Phone: ( for which no fee is
( ) Fax: ( ) 90.00 / hr
specifically listed (Y2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Subtotal: 7 5 A.
Suprv. Electrician signature, required: Plan review (25% of permit fee): ......--
Print name: Date: State surcharge (12% of permit fee): l • od
TOTAL PERMIT FEE: gei•
Authorized signature: This permit application expires if a permit is not obtained within IRO
days after it has been accepted as complete.
Print name: Date: •
Number of inspections allowed per permit.
I \Building \ Permits \ELC- PermitApp.doc 07/01/10 440 -4615T(11 /05 /COM/WEB
Electrical Permit Application - City of Tigard
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*
® Other: ethernet and video cables
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
1: \Building \Permits \ELC- PermitApp.doc 07/01/10