Permit CITY OF TIGARD ELECTRICAL PERMIT
Per
COMMUNITY DEVELOPMENT
Permit #: ELC2012 -00388
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/27/2012
Parcel: 2S110CB08200
Jurisdiction: Tigard
Site address: 12476 SW AUTUMNVIEW ST
Project: Domogalla Subdivision: MOUNTAIN VIEW ESTATES Lot: 7
Project Description: Add a breaker and connect prewired NC to disconnect. Relocate disconnect. Connect NC unit to disconnect.
Contractor: OWNER Owner: DOMOGALLA, DAVID
12476 SW AUTUMNVIEW
TIGARD, OR 97223
PHONE PHONE: 503 - 703 -0650
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 06/27/2012 $56.18
Specifics: Service or Feeder
1 ea 12% State Surcharge - 06/27/2012 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 ' accordance 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 ire you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 1 -0010 through OAR 952- 000 O. o may obtain a copy of the rules or direct questions to OUNC by cal g_503.232.1987 or 1.800.332.2344
In By: Permittee Signature: ► / Ii—
OWNER INSTALLATION ONLY
The installation is being mad • • . • • • . .1 I own which is not inte • ed for sale, lease or rent. (
OWNER'S SIGNATURE _ ..000/ � Date: d` 7 / 2—
CONT • CTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
� -nt n � r r Electrical Permit Applicatio L' =�1j grcr FOR OFFICE USE ONLY
City of Tigard Received . I Deteiv Permit No.: L
114
f �o/a - ee3
13125 SW Hall Blvd., Tigard, OR 97223 JUN 2 7 2092 Plan Review
/11 Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Other Permit:
1' I G A R U Inspection Line: 503.639 Cite y u s (, : =ti, Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov PUP p,�j�(� "lL� 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
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "I -2", "I -3 ",
Job no.: Job site address: 12476 SW AutumnView IOOHP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: Tigard, Oregon, 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Andrews Way Description I_ Qty. I Fee. I Total I
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Mt View Estates Lot no.: 07 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 I
Tax map /parcel no.: 655/B/7 R2150308
Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family 75.00 2
Add Breaker and connect prewired A/C circuit to Disconnect. Relocate Disconnect residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
1 foot from current location. connect A/C unit to disconnect. 200 amps or less 100.70 2
to PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: David Domogalla 601 amps to 1,000 amps 301.04 2
Address: 12476 SW AutumnView Over 1,000 amps or volts 552.26 2
City /State /ZIP: Tigard, Oregon, 97223 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (503)703 -0650 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
intended for e, rent, or exc an e according t ORS 447, 449, 670, an 701. 401 amps to 599 amps 168.54 2
Branch circuits new, alteration, or extension, per panel
Owner signature: / ea` Date: / L A. Fee for branch circuits with
® APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: B. Fee for branch circuits without L/ . ray
service or feeder fee, first / 56.18 J( ` 2
Contact name: David Domogalla branch circuit
Each add'I branch circuit 7.42 2
Address: 12476 SW AutumnView Miscellaneous (service or feeder not included)
City /State /ZIP: Tigard, Oregon, 97223 Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: (503) 703 - 0650 Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail: domogalla@comcast.net Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited - energy
Business name: By Owner panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (I hr min) 66.25/ hr
Investigation (I hr min) 66.25/ hr
City/State/ZIP: Industrial plant (I hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is
• specifically listed (%2 hr min) 90.00 / hr
CCB Lie.: Electrical Lic.: Suprv. Lie.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: ��
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): 4, ,7t
Authorized signature: TOTAL PERMIT FEE: ( .9 2
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: David Domogalla Date: 2/27/2012 • Number of inspections allowed per permit.
t: \Building \Permits \ELC- PermitApp.doc 07/01/10 440-4615T(t1/05 /COM/WEB