Permit JOB#
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. Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 Planck/Rec. # e -1 S 1.
Permit # CLCgfLS - DAS(p
��J Phone (503) 639 -4171 Date Issued G ` / / -`'t S
FAX (503) 684 -7297
CITY OF TIGARD TDD No. (503) 684 -2772 Issued by �r
Inspection (503) 639 -4175
I 1. Job Address: 4. Complete Fee Schedule Below:
Name of Development Number of Inspections per permit allowed
Address ( Z ( 04 9 I ?P+1-. 'F 11-1 ).iZ Cr Service included: Items Cost(ea) Sum
City /State/Zip TIGARD O R 4a. Residential - per unit J I� 4
� 1000 sq ft. or less f $110.00 11 V
�" G Each additional 500 sq. ft. or �� - 1
Name (or name of business) hn S
portion thereof $ 25.00
Commercial ❑ Residential 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
Installation, 200 mps or ies sn, or relocation 2
Electrical Contractor D.A. J E R 0 M E ELECTRIC
200 amps or less $60.00 2
Address P O B 0 X 7 51 201 amps to 400 amps 2
City HILLSBORO L L S B O R O State O R Zip 9 712 3 401 amps to 600 amps $120.00 2
`7 p 601 amps to 1000 amps $180.00 2
Phone No.648 -5144 FAX 648 -9723 Over 1000 amps orvotts $340.00 2
Contractor's License No. 3 4 -119 C Reconnect only $50.00
Contractor's Board Reg. No. 3 6 0 _1 4c. Temporary Services or Feeders
Installation, alteration, or relocation 2
Signature of Supr. Elec'n . S_ �„4_ 200 amps or less $50.00 2
License No. 2 8 7 7 S Phone N • 4 8- 5 4 4 201 amps to 400 amps $75.00 2
i 401 amps to 600 amps $100.00
Over 600 amps to 1000 volts
2b. For owner installations: see 'b' above.
Print 4d. Branch Circuits
rint Owner's Name
New, alteration or extension per panel
Address a) The fee for branch circuits with •
purchase of service or feeder fee. 2
City State Zip 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
not intended for sale, lease or rent. First branch circuit $35 00 2
$5
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) $10000
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 inspection $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 $ 1`b
5% Surcharge (.05 X total fees) $ 12s
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5b. 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 $ )
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