Permit L
CITY OF TIGARD Electrical Permit Application -y.
13125 SW HALL BLVD. Date Recd �- r4, ' C fC
TIGARD, OR 97223 Print or Type Date to P.E. ( t`; - I- 9 91
Date to DST lO' 3(j - 96
(503) 6294171 Incomplete or illegible applications will not be accepted Permit* C - 002-
•Rusted -swiR.a
Called
PL - W di_ BFc
1. Job Address: 4. Complete Fee Schedule Below:
Name of Delopment fi r► // Number of Inspec ; ons per permit allowed
Address ic� � / ',G.. /17 t', 2 Service inducted: Cost (ea) Sum •ini
City /State/Zip % Gf i't 4 a Residential - per unit
�/ _- 1000 sq. ft. or less $110.00 4
Name (or na e o usiness) - .7; Each addiionel 500 sq. n. •
portion thereof 325.00
Limited Energy $25.00 1
Commerci Residential ❑ Each Manufd Horn. • Modular
2a. Co tractor installation only: Dwelling Servi . or Feeder $68.00 2
(attach copy of all current l ense)
Electrical Contractor - li f . n after or Feeders rloccation
Address 200. • ps or less CZ) $60.00 X20 2
01 : ps to 400 amps $80.00 2
City Sate Zip amps to 600 amps G /) $120.00 42.-c... > 2
' 1 amps to 1000 amps $180.00 2
Phone No. i . er 1000 amps or volts $340.00 2
Job No. Reconnect only $50.00 2
Elec. Cont. Lice. No. Exp Date /,
OR State CCB Reg No. Exp Date 4c. Te porary Services or
Signature of Sur. Elec'n Feed
3 ..1 P � I . .tlon, alteration, or relocation S
2
License No. Exp Date 411111117 l''' amps or less L 9 $50.00
, 1 amps to 400 amps $75.00 2
Phone No. COT Business Tax or Metro # Exp.Date v �600a o �� $100.00 2
see if above.
2b. For owner installations: 4d. Branch Circuits
Print Owner's Name New, alteration or extension per
Address p ale
City State 'INV. w a) purchase of service o f eeder ` 7i 2
Phone No. 1B°
The installation is being made on prope '• I o n w • this no'' tended b)
Each ee f rb br G a ch circuits $ 2
without 2
for sate, lease or rent. purchase of service or feeder
fee.
Owners First branch circuit $40.00 j
Signatu " � �%f Each additional branch Orcuit $ 000 2
9 2
3. Plan Review section (if requ - d): -- h`� (Ser or feeder not $100.00 4e. Miscellaneous $40.00 2
Please check appropriate item and en r fee in sectio 5B.
included) i
4 or more residential units in one struf1 re Each pump or irrigation circle
Service and feeder 225 amps or mo = Each sign or outline lighting
System over 600 volts nominal Signal circuit(s) or a limited energy $35.00
Clasr. area or structure contai' ng special occupancy panel, alteration or extension $55.00
as described in N.E.C. Chapter ' Minor Labels (10) $55.00
4f. Each additional
Submit 2 sets of plans wit application where any of the inspection over the S
above apply. Not require • for temporary construction allowable in any of the S
above
services.
Per inspection S
Per hour
NOTICE In Plant $
PERMITS BECOME VOID IF WORK OR CONSTRUCTION $ 00
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5 . Fees:
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A 5a. Enter total of above fee 5 3 a , a�
PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
5% Surcharge (.05 X total i
fees) $ ,/ ^_ :�5
tosoo ec. °ec sis Subtotal 1 (.Y I •
•
5b. Enter 25% of line A for
Plan Review if required
(Sec.3)
Subtotal
❑ Trust Account # iJ i? - Q, SD
Balance Due 1/ 15 -� 0
i