Permit CITY OF TIGARD ELECTRICAL PERMIT
a COMMUNITY DEVELOPMENT Permit #: ELC2009 -00217
T I G A R D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 05/13/2009
Parcel: 2S112DD01600
Jurisdiction: Tigard
Site address: r 1.5_495_SW SEQUOIA_P_KW_Y_1.50
Subdivision: Lot: 0
Project: Accelertion Chiroprictic
Project Description: Install (5) branch circuits.
Owner: FEES
PACIFIC REALTY ASSOCIATES Quantity Description Date Amount
ATTN: N PIVEN, 15350 SW SEQUOIA PKWY 5 crt Branch Circuits 05/13/2009 $73.45
#300
PHONE: wo /Purchase Service or
Feeder
1 ea 12% State Surcharge - 05/13/2009 $8.81
Contractor: Electrical
FIVE STAR ELECTRIC, INC.
PO BOX 555
•
BANKS, OR 97106
PHONE: 503 - 324 -0948
FAX: 503 - 324 -0973
. Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $82.26
Required Items and Reports (Conditions)
•
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the
180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through AR 952 -001 - 0100. You may obtain a con of the rules ules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: ' - �� " Permittee Signature: �
� Q �� �� ��
L
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNER'S SIGNATURE: Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for an Inspection that business day.
This permit card shall be kept In a conspicuous place on the Job site until completion of the project
Approved plans are required on the job site at the time of each inspection.
' From: 05/11/2009 13:27 #630 P.002/003
Electrical Permit Applicatil . R O USE ONLY .
City of Tigard B2 FFIVED Dale!ByReceive` d ' O . Pnm � t�o � 21 D 7
13125 SW Hall Blvd.. Tigard. OR Plan Review
0 Phone: 503.639.4171 .. .: Date/By: Other Permit:
Ti G p R D Inspection Line: 503.639.4175 AY 1 1 2009 Date Ready /By ® See Page 2 for
Internet: www.tigard or.gnv �+� Notified/Method: C C7) Supplemental Information
TYPE OF] �/ OF t TII 1 G � ARD PLAN REVIEW
❑ New construction ® Add ition /a�1UrlIILL1H/IIe J$ ckm @Ilt3IUI t�� V Please check all that apply (submit 2 sets of plans w /items checked below I
❑ Service or feeder 400 amps or more ❑ Building oser three stories
❑ Demolition ❑ Other: where the available fault ctnre,n
❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at ISO 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 ❑ Other: ❑ Fire pump. ❑ Installation of 75 K VA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger sepal ately del iced system.
0 Addition of new motor load of ❑ •A' "F" "I.2 ". °L1 "
Job no.: FS1469 Job site address: 15495 SW Sequoia Parkway 10OHPor tutee. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle packs.
City /State /ZIP: Tigard, OR 97224 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: 150 [ name: Acceleration Chiropractic ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description P I Ql v. I Fee. ) Twat I .
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1.000 sq. ft. or less 145.15 4
Ea. add'I 500 sq. ft. or portion ' 33.40 1
Tax map /parcel no.: _ Limited energy, residential
75.00 2
DESCRIPTION OF WORK (with above sq. fl.)
Limited energy, multi- family 75.00 2
Install 5 branch circuits residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1.000 amps 240.60 2
Address: Over 1.000 amps or volts 454.65 , 2
City /State / "LIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease. rent. or exchange. according to ORS 447. 449. 670, and 701. 401 amps to 599 amps 133.75 2
Branch circuits - new, alteration, or extension, per panel
Owner signature: _Date: A. Fee for branch circuits miii,
❑
I
APPLICANT ❑ CONTACT PERSON above service or feeder fee.
each branch circuit 6.65 2
Business name: B. Fee for branch circuits
without service or feeder lee, I 46.85
Contact name: first branch circuit 46.85 2
Address: Each add'I branch circuit 4 6.65 26.60 0
Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 90.90 2
dwelling, service and /or feeder
Phone: ( ) Fax:: ( ) Reconnect only 66.85 2
E -mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name: Five Star Electric, Inc. Signal circuit(s) or limited-
energy panel, alteration, or
Address: PO Box 555 extension. Describe: Page 2 2
City /State /ZIP: Banks, OR 97106 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone: (503) 324 -0948 Fax: (503) 324 -0973 Investigation per hour (1 hr min) 62.50
CCB Lie.: 15$231 Electrical Lie.: 34 -665C Suprv. Lie.: 4622S Industrial plant per hour 73.75
1C-3 t • (U ELECTRICAL PERMIT FEES
Suprv. Electrician signature. required: �. Subtotal_ 73.45 j
• Print name: Royal Stearns z"-----11 Date: 5/11/2009 Plan review (25% of permit fee):
State surcharge (12 %ofpermit fee): 8.81
Authorized signature: TOTAI. PERMIT FEE: 82.26
This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
" Number of inspections allowed per permit
1 lnnilding\PCrmit;\EtC- PermitApp disc 0503/0° 440 - 4515Tt I ItO5IC OM' W'lia
52. 26