Permit \J O1D
C ° Community Development . V s�i Z
Ali
Request for Permit Action
TIGARD
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
- Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ArCity Staff
(check one)
REFUND OR Name:
7\)/A
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip: .
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
❑ CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: e g0 /9.— DO ag`'
Site Address or Parcel #: P/66 J 77 4) 6
Project Name: — /;2;; j y HI bbLE '_-IrtDpL
Subdivision Name: p,.., / /� , Lot #:
EXPLANATION: o I b !-lI 5 �7ivoTYf /L P�-1, r W4-6 .
e -2 - 73 /S$ictb . i - etCao /a-60 ? 3
Signature: , , p ../14 , r ` Date: 2
Print Name: `, t jZig z aD f /./ •
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date PINMEOW11 Rte to Bid. Admin: Date J ®® B r
Refund Processed: Date BAPV Invoice Processed: Date By
Permit Canceled: Date 7 /9 //Z By ;; Parcel Tag Added: Date By
Receipt # Date Method Amount $
•
I:\ Building \Forms \RegPermitAction.doc Rev 04/26/2011
Electrical Permit Application" FOR OFFICE USE ONLY
of Tigard s �. AY 201 ' ; ' tt�Lt� m Permit No.: eL ' �/o'l■DtePt
13125 SW Hall Blvd., Tigard,OR 97223
' C Phone: 503.718.2439 Fax: 503.598.1960 7 , 9 / Other Permit:
TI G A It D Inspection Line: 503.639.4175 CITY OF 1G RD -I"' Date Ready/By: surfs: ® See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
El New construction go Addition/alteration/replacement Please check all that apply (submit I. 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
❑ I - and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder I-Other: 5cif/cv G ❑ 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 ", "1 -3 ",
Job no.: Job site address: 140 J ) 97 Me" I OOHP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State /ZIP: t 764gp ciao ''7 , 4 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: Project name: Jz&I tH f / L 6' �rilLsr/ ID Service or feeder 600 amps or more.
� L � ++LL � FEE SCHEDULE
Cross street/directions to job site: Description I Qn• I Fee. I Total I •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
sq. 75.00 2
DESCRIPTION OF WORK ( with above q• ft. )
r
A c 4f/ 4, p a ;
Limited energy, muhi- family
C f �9I u'fSJIe catisi residential (with above sq. ft.)
75.00 2
J � Services or feeders installation, alteration, and/or relocation
4,610 W1��
200 amps or less 100.70 2
. PROPERTY OWNER I ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name: 7-74 f' L'fvi Dlricr 601 amps to 1,000 amps 301.04 2
Address: 4,9'447 se9,4420 ...57-: Over 1,000 amps or volts 552.26 2
City/State /ZIP: 77(,44.7 ae 9722.3 Temporary services or feeders installation, alteration, and/or
relocation .
Phone: (S ' 3 ) 431 - 4 0aa 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
401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
Vt APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: , 062 , 05 : _ a„ ,eooe, B. Fee for branch circuits without
service or feeder fee, first / 56.18 % .18 2
Contact name: g/� Co��13(� y branch circuit
���/�v� Each add'I branch circuit /2 7.42 g7,04 2
Address: 90 7 SC(/ .57,t S7 Miscellaneous (service or feeder not included)
Q Each manufactured or modular
City/State /ZIP: ! 72.40..r dwelling, service and/or feeder 67.84 2
Phone: ( ) 24 Fax: : ( ) Reconnect only 67.84 2
E -mail: br ff. er4) 1 ••• 4/9�/f. C ' ' Pump or irrigation lnig ring 67.84 2
67.84 2
Sign or outline lighting
ONTRACTOR Signal circuit(s) or limited energy
Business name:
panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City/State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) I Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed (% hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: /4 S', 22
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE:
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: • Number of inspections allowed per permit.
I:\ Building\Permits\ELC - PermitApp.doc 07/01 /10 440.4615T(11/05 /COMIWEB
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*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY: l
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000) •
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls °
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ • Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1: \ Building \Permits\ELC- PermitApp.doc 07/01/10