Permit C ITY OF T'I^ARD ELECTRICAL PERMIT
• `� PERMIT #: ELC2005 -00615
DEVELOPMENT SERVICES DATE ISSUED: 8/22/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 2S103DD -00800
SITE ADDRESS: 13815 SW PACIFIC HWY 110 ZONING: C -G
SUBDIVISION: LOT : JURISDICTION: TIG
Project Description: Relocate 200 amp panel, add (12) circuits (1) sign, low voltage data & data.
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG: 1
LIMITED ENERGY: 401 - 600 amp: SIGNAL/PANEL: 2
MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: 1 W /SERVICE OR FEEDER: 12 PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
D.W. SIVERS COMPANY WEST LINN ELECTRIC, INC
4730 SW MACADAM AVE PO BOX 2013
#101 OREGON CITY, OR 97045
PORTLAND„ OR 97201
Phone: Phone: 503 - 656 -7337
FEES Reg #: LIC 00082566
SUP 3722S
Description Date Amount ELE 3 - 302C
[TAX] 8% State Surcharge 8/22/2005 $29.08
[ELPRMT] ELC Permit 8/22/2005 $363.50 REQUIRED ITEMS AND REPORTS
Total $392.58
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws.
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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those
rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules q it ct questions to OUNC at
503 - 246 -6699 or 1- 800 -33 344. eL
Issued By: ,7 Sl 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 DATE:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N: 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.
. . Electrical Permit AP tz!f.Tf.i. I L VED FOR OFFICE USE ONLY
City of Tigard Received , I ■ . Perm No.: 6 �� i , in `' 111
13125 SW Hall Blvd., Tigard, OR 97223 2 2005 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 ' �+ J - i p� , Other Permit:
Inspection Line: 503.639.4175 Date Read
See Page 2 for
Internet: www.ci.tigard.or.us CITY OF TIGARD Notified/Method: �� Supplemental Information
E UnSION PLAN REVIEW
❑ New construction Addition/alteration /replacement Please check all that apply:
❑ Demolition ❑Other: ❑Service over 225 amps, comm'I ['Hazardous location
❑Service over 320 amps — rating ❑ Buildng over 10,000 sq. ft.,
CATEGO OF CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential
❑ 1- and 2- family dwelling Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
El Multi- family ❑Master builder ❑Other: ❑Building over three stories ❑Feeders, 400 amps or more
DOccupant load over 99 persons ❑Manufactured structures or
JOB SITE INFORMATION AND LOCATION ❑ Egress/lighting plan RV park
Job no.: I Job site address: / 3 gl.5so fi, e ; . , 4 . 4n/ ❑Health -care facility ❑Other:
Submit 2 sets of plans with any of the above.
City/ State/ZIP: l 0 2 _ 9 -4-� ,3 The above are not applicable to temporary construction service.
Suite/bldg./apt no.: (Project name: rl 1 FEE* SCHEDULE
�ar /)`� / M Description I Qty. I Fen I Total I ••
Cross street/directions to job site: New residential single- or multi- family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 • 4
Subdivision: I Lot no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: x/63 230 6 OS' O -C-' Limited energy, residential 75.00 2
Limited energy, non - residential 75.00 2
DESCRIPTION OF WORK. Each manufactured or modular
dwelling, service and/or feeder 90.90 2
Services or feeders installation, alteration, and/or relocation
200 amps or less / 80.30 . d 2
201 amps to 400 amps 106.85 2
❑ PROPERTY OWNER I ❑ TENANT
401 amps to 600 amps 160.60 2
N 601 amps to 1,000 amps 240.60 2
• Address: Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
Phone: ( ) I Fax: ( ) relocation
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 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT 1 ❑ CONTACT PERSON A Fee for branch circuits with
service or
Business name: branch circuit fee, each f 6.65 7 J 2
Contact name: B. Fee for branch circuits I
without service or feeder fee, 46.85 2
Address: each branch circuit
Each add'I branch circuit 6.65 2
City/State/ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle 53 2
Phone:
( ) I Fax: : ( ) e
Sign or outline lighting i 53.40 .53 '>' 2
E -mail: _ Signal circuit(s) or limited-
! CONTRACTOR energy panel, alteration, or
extension. Describe: pZ Page 2 I� - 61 2
Business name: ZAje,. A_ 'l , „)A, 61 a ��,, �� L
Address: f 8, , d l Each additional inspection over allowable in any of the above
� Per inspection 62.50
City/State/ZIP: O (' C � c,,,.) `. d� `/,2 C , ""7,61 Investigation per hour (1 hr min) 62.50
Phone: (5 656_, 4 7 s I Fax: ( ) Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES*
CCB Lic.: 56 (p Electrical Lic.: 3. Suprv. Lic.: 6 7,1 c... Subtotal j f3 ,.)1)
Suprv. Electrician signature, required: Plan review (25% of permit fee)
^
State surcharge (8% of permit fee) �9 8
Print name: n/
dA Oic fydvio,v Date: crA., a
` TOTAL PERMIT FEE 3 / 51
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete
Print name: Date: • Fee methodology set by Tri- County Building Industry Service Board
•• Number of inspections per permit allowed.
i:\ Building \Pennits\ELC- PenitApp.doc 12/03 440-4615T(10/02/COM/w®
• Electrical Permit Application - City of Tigard '
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
• RESIDENTIAL WORK ONLY: —_ —
Fee for all residential systems combined........ $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
• ❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
•
❑ Vacuu • Systems*
❑ Other: •
COMMERCIAL WORK ■ NLY: Fee for each commercial sys 5.00
(SEE OAR 918- 260 -260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
•
❑ Boiler Controls •
❑ Clock Systems
❑ Data Telecommunication Installat' s n
• ❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
• ❑ Intercom and Paging Sy- ems
❑ Landscape Irrigation ' ontrol*
❑ Medical
❑ Nurse Calls
. ❑ Outdoor ndscape Lighting *.
❑ Prot we Signaling •
• Other
. Total number of commercial systems:
*No licenses are required. Licenses are required
• for all other installations
is\ Building \Permits\ELC- PetmitApp.doc 04/03 •
, . 2 -11 -1995 7 :16PM FROM P.1
•
,✓ •
•
•
Building Division
• Request for Permit Action or Refund •
City of Tigard
TO: • CITY OF TIGARD
Permit System Administrator •
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff.
PP Y
(chock one)
Name:
(Business or individual) &des -, ))
lam.: /JA/
jr / Mailing Address: PQ R a 3
C ity /State /Zip: r econ CA 1A A .0P- � C 45
VOID �
PhoneNo.: 5c8- (0 "437. c€ A■ 701 - coi
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (i):
g y eANCEL PERMIT APPLICATION. •
REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: • LX a6 a,5 - 0 o t-s
Site Address or Parcel #: 5s W Pp c ; -�� �,, 1\o
Project Name: r l; t_: c„ 's c
Subdivision Name: Lot #:
EXPLANATION: �5t..� r < �� ac e� Gk.", vJ(�e. r eX42
G 1 ( - co/Ara. & - 6 r t,,i. L c ) n Po f
•
Signature: Date: l
Print Name: h eo A)A S• 6'17e$ v o": •
Refund Policy S i9s1P—
•
1. The Building Official may authorize the refund of
u) any fee which was erroneously paid or collected.
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payer in the same method in which payment was received
F()IZ OFFICE USE ONLY
Rte to Sys Admin: Date, j X r By Ric to Bldg Admin: Date //' of By d1:•-■
Refund Processed: Date i// / 03 - By #J. Invoice Processed: Date By
Permit Canceled: Date // 3 /p B • arcel Tag Added: Date By
Receipt #,V2105"- .)ate0 —qo S�J Meth.. 6.c_ . • Amount S, a,S$'
1:\Building1F ms(1te4PermitActinn- B1dg.doc Rev 10/17/05 /�Mh4tit