Permit C ITY OF TIGARD ELECTRICAL PERMIT
PERMIT #: ELC2005 -00868
1:41111t DATE SERVICES DATE ISSUED: 11/4/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2S111 BD -00309
SITE ADDRESS: 09945 SW PEMBROOK ST ZONING: R -3.5
SUBDIVISION: PEMBROOK HEIGHTS LOT : 009 JURISDICTION: TIG
Project Description: (1) branch circuit for furnace.
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:
LIMITED ENERGY: 401 - 600 amp: SIGNAL /PANEL:
MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10):
SERVICE/FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 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:
BILL RACZKOWSKI OWNER
9945 SW PEMBROOK AVE
TIGARD, OR 97224 -4781
Phone: 503 - 860 -3839 Phone:
FEES Reg #:
Description Date Amount
[ELPRMT] ELC Permit 11/4/2005 $46.85
[TAX] 8% State Surcharge 11/4/2005 $3.75 REQUIRED ITEMS AND REPORTS
Total. $50.60
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 or direct questions to OUNC at 503 - 246 -6699 or
1- 800 - 332 -2344.
Issued By: '� Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on pro own which is not intended for sale, lease, or rent.
OWNER'S SIGNATURE: r 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.
Nov 03 05 06:19p J.PauI Cessaro 503 697 0675 p.1
• • Electrical Permit Aaal IV E D l e , 1, e ; i c l: l I'\] 1
City of Ti D ate : // " b .111 Pali' Na: L _ .. S i Q , 4
' .
13125 SW Hall Blvd., Tigard, OR 97223
NOV i zoo , '— .., ..:, - P Deb= Permit
-
Phona 503.639.4171 Fax: 503.598.1960
Inspection Line: 503.639.4175 —F- ' 1 1 J Date Ready/By: See Pape 2 for
Internet: www.ci.dgard.or.ne CITY OF TIGARn Noticed &Method: Supplementaltafonmaana
I S ION PIAN REVIEW
❑ New construction ® Additionfaltastioo/teplacement Please chat all that apply:
Other ❑Sexvioe over 225 amps, oomm, ❑Hazardous location
CATEGORY OF CONSTRUCTION of over 320 amps — rating QBuildngover 10,000 sq. S,
of 1- and 2- family dwellings 4 or mom new residtatial
® l- and 2-family dwelling ❑ CommerciaUtodustrial ❑ Accessory building ❑Systems ova 600 volts nominal units in one stnn:tnte
❑ Multi - family ❑ Master builder 0 Other ❑Btnldiag ova three stories ❑Prudes, 400 amps or more
JOB SITE INFORMATION AND LOCATION ❑ load aver 99 persmts ❑RV t>faettued struecnaes or
❑E& tdiOg plan park
Job no.: I Job site address: 9945 SW Panbroolt Ave ['Health-care facility Daher:
- Submiti sets of plans with any
City/StatelZIP: Tigard, Oregon 972244781 The above not applicable temporary le to oldie ay construction service:
Suite/bldgJapt. no.: I Project name: FEE* SCHEDULE
neetpt oa I qv I fee. 1 Tem I N
Cross street/directions to job site: New residential singlet or multi - family dwelling unit:
Includes studied garage.
1,000 sq. R or less 145.15 4
Subdivision: I Lot no.: Ea add, 500 sq. R or portion 33.40 1
Tax map/parcel no.: Limited d energy, residential 75.00 2
Limited energy, non- residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
Add 20 amp branch circuit to gas furnace-
dwelling envies arellur feeder 90.90 2
Services or feeders installation, alteration, and/or relocation
200 amps or leas 80.30 2
❑ PROPERTY OWNER I ❑ TENANT 201 amps to 400 apps 106.85 2
Bib 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Addrxsm 9945 SW Pembrook Ave. Ova 1,000 amps or volts 454.65 2
City/StateJZIP: Tigard, Oregon 97224 Reconnect only �'� 2
Temporary services or feeders insmllatiron, alteration. and/or
Phone: (503 860 3839) I Fax (503 218 5148) rdtrea
ion
200: or lea 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 atn to 400 a 10030 2
intended for sate, or aaordumg to ORS 447, 449, 670, and 701. -
401 amps to 600 amps 133.75 2
Owner signffi Date: It I4) 05 Branch dunks — new, alteration, or extension, per panel
❑ APFUCANT 1 ❑ CONTACT PERSON A. Fee for branch circuits with
service or littler fee, each
Business name: branch circuit 6.65 2
B. Fee for branch circuits
name: Contact rse: without service or feeder tae, ,,
Address:
each branch circuit 46.85 2
Each add, branch circuit 6.65 2
City /StatrJZIP: Mlscellaneons (service or feeder not included)
Phone ( ) I Fax: : ( ) Pumzor irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E -mail:
Signal circuits) or limited-
CONTRACTOR energy panel, alteration, or
ex
Business name:
tension. Deuxnbe: Page 2 2
Address: Each additional Inspection over allowable In any of the above
Per inspection 62.50
City /State/ZIP: gafion per bemi (1 am) 62.50
• phone: ( ) I Fatc ( ) industrial plant pa hour 73.75
ELECTRICAL PERMIT FEES*
CCB Lic.: I Electrical Lic.: I Suprv. Lic.: Subtotal cg gi
Suprv. Electrician signature, required: Plan review (25% of permit fte)
Print name: 1138te: State surcharge (8% of permit See) 7 q 5
- TOTAL PERMIT FEE S i f 13
Authorized sign tore: '[tile peewit application expires it a permit c not obtained within ISO
Print ttama I Date: days after it has been accepted as ®plete
• taco mt�odology, set by 1b•Cmmq Baran Industry service Board
•• Number ofd speetions per permit allowed.
BatikfiniblppAlao MAXI 441aattutwi ncoavwEB
I
CITY OF TIGARD -
BUILDING DIVISION L PERMIT #: EL.c b 03- a o F6
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: 99145 CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: /1 /iq/Q5 Pour Time:
Code # Inspection Description Confirm # Contact # Message
N5 \I oa /l l - o
Corrections /Comments /Instructions:
I -111
.: ; �•
• 1,-.
•
PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: � Date: S ' Phone #: (503) 718 -