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Permit • CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: ELC2012 00504 T EGA.RD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/28/2012 Parcel: 2S103BA01000 Jurisdiction: Tigard Site address: 12400 SW 121ST AVE Project: Ausbie Subdivision: LERON HEIGHTS NO.2 Lot: 28 Project Description: (6) branch circuits and (1) 200 amp service Contractor: L & K ELECTRIC Owner: AUSBIE, DONNA D 10122 SE SHADY LN 12400 SW 121ST AVE DAMASCUS, OR 97089 TIGARD, OR 97223 PHONE: 971 - 506 -8351 PHONE: FAX: 503 - 663 -0343 FEES Quantity Description Date Amount 1 ea Services or Feeders - 200 08/28/2012 $100.70 • Specifics: amps or less 6 crt Branch Circuits w /Purchase 08/28/2012 $44.52 Type of Use: SF Service or Feeder Class of Work: ALT 1 ea 12% State Surcharge - 08/28/2012 $17.43 Electrical Type of Const: Occupancy Grp: Total $162.65 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 OA 2 -001- 90. You may obtain a c py of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: 0d A4 U C 1 ' / 0kL 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' 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. • CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: ELC2012 00504 T EGA.RD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/28/2012 Parcel: 2S103BA01000 Jurisdiction: Tigard Site address: 12400 SW 121ST AVE Project: Ausbie Subdivision: LERON HEIGHTS NO.2 Lot: 28 Project Description: (6) branch circuits and (1) 200 amp service Contractor: L & K ELECTRIC Owner: AUSBIE, DONNA D 10122 SE SHADY LN 12400 SW 121ST AVE DAMASCUS, OR 97089 TIGARD, OR 97223 PHONE: 971 - 506 -8351 PHONE: FAX: 503 - 663 -0343 FEES Quantity Description Date Amount 1 ea Services or Feeders - 200 08/28/2012 $100.70 • Specifics: amps or less 6 crt Branch Circuits w /Purchase 08/28/2012 $44.52 Type of Use: SF Service or Feeder Class of Work: ALT 1 ea 12% State Surcharge - 08/28/2012 $17.43 Electrical Type of Const: Occupancy Grp: Total $162.65 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 OA 2 -001- 90. You may obtain a c py of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: 0d A4 U C 1 ' / 0kL 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' 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. AUG -28 -2012 07 :30 AM IR 49VEItit' 5036630343 ` P.01 Electrical Permit Ap l' IIc tion I t tit t tl: t it 1 .I. t t1 .) -- -.- AUG 2 8 2012 Received Ma Permit No.: at. aola —Cf) O City S W Tigard Hall Blvd.. Tigard, OR 07 OFT ARD DateB Plan Review Other Permit 13125 S IL W ��� /�17 2d (1 Q Q / d Phone: 503.718.2439 Fax: 503. SIC 1 V SOP Date R ° gf See page 2 for Inspection Line: 503.639. u 1 Date Ready /By: Supplemental 'Information t , , : u t , NotiRed/Method: Internet: www.tigard- or.gov _ • • TYPE OF WORK .. PLAN RFrYIEW • • Please cheek all that apply (submit isms of plans w /items checked below): ❑ New construction Addition /alteration/replacement 0 Service or feeder 400 amps or more 0 Building over three stories. ❑ Demolition Q Other: where the available fault current 0 Marinas and boatyards. • J ' CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings. less to ground, or exceeds 14.000 0 Commercial -use agricultural ® 1 • and 2- family dwelling ❑ Commercial /Industrial ❑ Accessory building amps for all other installations. buildings. n of 75 KVA or 0 0 bilder � Master u [] Other: 0 Fire pump. ❑ Multi-family ❑ C! Emergency system. larger separately derived system. JOB Si(TE • INFORMATION AND 'LOCATION 0 Addition or new motor load of 0 "A" "E", "1.2" "1-3", 100HP or more. occupancy. Job no.: Job site address: 12400 SW 121st St 0 Six or more residential units. 0 Recreational vehicle parks. O Health -care facilities. 0 Supply voltage for more then Ciry /State/Z1P: Tigard 0 Hazardous locations, 600 volts nominal. 0 Service or feeder 600 amps or morn Suite/bldg. /apt no.: Project name: FEE SCHEDULE Cross street/directions to job site: _noudntten I Acv I Fee. Tee . New residential single- or multi - family dwelling unit. Includes attached garage. Lot no.: 1,000 sq. ft. or less 168.54 4 Subdivision: Ea. add'I Soo sq. ft. or portion 33.92 I Tax map /parcel no.: Limited energy. residential 75.00 2 . D E S C R I P T I O N O F WORK • .. (with above sq. ft.) Limited energy, multi - family 75.00 2 200A service with 6 branch circuits residential (with above sq. Services or feeders Installation alter and/or relocation 200 amps or less 1 100.70 _ 100.70 2 © PROPERTY OWNER 1 . la TENANT 201 amps to 400 amps 133,56 2 401 amps to 600 amps 200.34 _ 2 Name: Donna Ausble 601 amps to 1,000 amps 301,04 2 Address: 12400 SW 121st Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation, alteration, and/or City /State /ZIP: relocation Phone: (503)984 -48 200 amps or less 86 j Fax: ( ) 1 5 2 9 5 ..3 0 6 8 l 2 201 amps W 400 amps 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. . 401 elreulta — new, alteration. or extension, r panel Owner signature: Date: A. Fee for branch circuits with 0 APPLICANT " •I © CONTACT 'PERSON above service or feeder fee. 6 _ 7.42 44.52 2 each branch circuit Business name: B. Fee for branch circuits without service or feeder fee, first 56.18 2 Contact name: branch circuit Each add'I branch circuit 7.42 2 Address: Miscellaneous (service or feeder not Included) Each manufactured or modular 67,64 2 City/State/ZIP: dwelling, service and/or feeder Phone: ( ) I Fax:: ( ) Reconnect only 67.884 2 Pump or irrigation circle 67.84 2 E -mail: Sign or outline lighting 67.84 2 CONTRACTOR . Signal circui or limited energy Business name: L & K Electric, Inc Panel, alteration, or extension. Page 2 2 Each additional Inspection over allowable In any of the above Address: 10122 SE Shady Lane Additional inspection (1 hr min) 66.25/ hr Investigation (I hr min) 66.25 / hr City/State/ZIP: Damascus. OR 97089 Industrial plant (1 hr min) 78.18/ hr Phone: (971) 506 -8351 1 Fax: (503) 663 -0343 Inspections for which no fee is 90.00/ hr specifically listed ('A hr min) CCB Lic.: 6 i Electrical Lic.: 26-I 180C Suprv. Lie.: 4975 S ELECTRICAL PERNDT- FEES..' ' Subtotal: 145.22 Suprv. Electrician signature, required: .tom .../1111. n► .— ... Plan review (25% of permit fee): ' Print name: Larry Peterson pate: 8/28/2012 State surcharge (12% of permit fee): 17.43 TOTAL PERMIT FEE: 162.65 Authorized signature: Thts perm applteadon expires If a permit Is not obtained within la0 days after It has been accepted es complete. Print name: Larry Peterson 1 Date: 8/28/2012 • Number of inspections allowed per permit. l:l auiding1Psrntlu \ELC•PcrmitApp.doe 07/01no 440.461r1( HMS/COMMIS