Permit QITY OF TIGARD ELECTRICAL,PERMIT
PERMIT #: ELC2004 -00389
j DEVELOPMENT SERVICES DATE ISSUED: 6/28/2004
13125 SW Hall Blvd.. Tigard, OR 97223 (503) 639 -4171
PARCEL: 1S134CD-06800
SITE ADDRESS: 11756 SW SUMMER CREST PL
SUBDIVISION: BURLWOOD NO.3 ZONING: R -4.5
BLOCK: 01 LOT : 028 JURISDICTION: TIG
Project Description: 1 elec. service. •
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: 2 W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 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:
LHOTKA, CRAIG A OWNER
11756 SW SUMM ERCR EST PL
TIGARD, OR 97223
Phone: Phone:
Reg #:
FEES
Description Date Amount
Required Inspections
[ELPRMT] ELC Permit 6/28/2004 $80.30
[TAX] 8% State Surcharge 6/28/2004 $6.42 Rough -
Elect'l Service
Total $86.72 Elect'l Final
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 am 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: Permit Signature? C , CCU JELA4
OWNER INSTALLATION ONLY
The installation is being made on I own which is not intended for sale, lease, or rent.
OWNER'S SIGNATURE: fi �.4 . ()
nd h U-4-1 DATE:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N: DATE:
LICENSE NO:
Call 639 -4175 by 7:00pm for an inspection the next business day
Electrical Permit Application FOR OFFICE USE ONLY '
City of T1igaid Received p / ./ /
DateB : / / D PermitNo.: .Q
'te 0 41
13125 SW Hall Blvd., Tigard, OR 97223 Plan Revie
- , +\
Phone: 503.639.4171 Fax: 503.598.1960 / 'ai Date/By: Other Permit:
Inspection Line: 503.639.4175 e Date Ready/By: J 10 See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: -( 1 Q... Supplemental Information
- TYPE OF. WORK ' .- PLAN REVIEW, .-'
❑ New construction ❑ Addition/alteration/replacement Please check all that apply:
11 Demolition ❑ Other: ❑Service over 225 amps, comm'I 0 Hazardous location
❑Service over 320 amps — rating DBuildng over 10,000 sq. ft.,
CATECORY'OF •CONSTRUCTION of 1- and 2- family dwellings 4 or more new residential
❑ 1 and 2 family dwelling ❑ Commercial/industrial ❑ Accessory building ['System over 600 volts nominal units in one structure
El Multi - family ❑ Master builder ❑Buildin over three stories ❑Feeders, 400 amps or more
❑ Other:
❑Occupant load over 99 persons OManufactured structures or
- JOB SITE INFORMATION AND LOCATION ❑Egress /lightingplan RV park
Job no.: Job site address: ti St.0 S C ft piggy Cresk pt DHealth facility ❑Other
Submit 2 sets of plans with any of the above.
City/State /ZIP: " cy yC{ 002 97,34_3 The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: Project name: FEE* SCHEDULE • - '
�. 1 Description I Qty. I Fee. I Total
Cross street/directions to job site: (15 y 4 rlt- 6 S t,t s py r ci O" New residential single- or multi - family dwelling unit.
1 Includes attached garage.
6 SC c . j._r Cie 5 4 P �. 1,000 sq. ft. or less 145.15 4
Subdivision: Lot no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
1 Limited energy, non - residential 75.00 2
DESCRIPTION OF WORK Each manufactured or modular
- dwelling, service and /or feeder 90.90 2
Services or feeders installation, alteration, and/or relocation
200 amps or less / a 80.30 78,30 2
,� PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: Cyq. Lk&A 601 amps to 1,000 amps 240.60 2
Address: s ..ine Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State /ZIP: Temporary services or feeders installation, alteration, and/or
Phone: 6Z'3 ) S9 Q “Q"‘ Fax: (501 ) s.6,1 relocation
53 200 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 600 amps 133.75 2
Owner signature: Date: Branch circuits — new, alteration, or extension, per panel
❑ APPLICANT ❑ CONTACT PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee,
each branch circuit 46.85 2
Address:
Each add'l branch circuit 6.65 2
City/State/ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle 53.40 2
Phone: ( ) Fax: : ( )
Sign or outline lighting 53.40 2
E -mail: Signal circuit(s) or limited -
CONTRACTOR . energy panel, alteration, or
extension. Describe: Page 2 2
Business name: p ui J 1 -_
Address: Each additional inspection over allowable in any of the above
Per inspection 62.50
City /State /ZIP: Investigation per hour (1 hr min) 62.50
Phone: ( ) Fax: ( ) Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES* .
CCB Lic.: Electrical Lic.: Suprv. Lic.: Subtotal gQ 30
Suprv. Electrician signature, required: Plan review (25% of permit fee)
Print name: Date: State surcharge (8% of permit fee) (p, • f 2
TOTAL PERMIT FEE 8t , 1„9....
XAuthorized signature:Co (� This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete
Print name: C.01( C<.' ( r , e1/ Date: ( - a, e - CI " Fee methodology set by Tri- County Building Industry Service Board
l ( Number of inspections per permit allowed.
i:\ Building \PermitstELC- PemtitApp.doc 12/03 440 -4615T(I0 /02/COM/WEB
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:
COMMERCLAL WORK ONLY: I
Fee for each commercial system $75.00 •
(SEE OAR 918- 260 -260)
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
is\ Building \Pmnits\ELC- PcmitApp.doc 04/03
CITY OF TIGARD . 24 -Hour
BUILDING Inspection Line: (503) 639 -4175 MST v(-)/
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Re nested 6 AM PM BUP
Location r' r' S(o Suite f L— MEC
Contact Person � Ph ( ) 5,0 — f a- l / PLM
Contractor Ph ( ) �- C� 7 —9 a3? SWR
BUILDING Tenant/Owner ELC R/O0V
Footing
Foundation ELC
Ftg Drain Access: ELR
� _
Crawl Drain U
Slab Inspection Notes: -- SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear f, ( r � � c
Framing CC
Insulation
Drywall Nailing • 1 / 4"`
Firewall s , !� l e / / 1L
Fire Sprinkler �
Fire Alarm
Susp'd Ceiling 1 • • /
• Roof r : • ' �/ .0/
Other: _ '
'ASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer //�� ') �1 . 4 e 4,5
Rain Drains ( "G//
Catch Basin / Manhole I
Storm Drain
Shower Pan
Other: I f
�
eigt PART —
' ANICAL
Post & Beam
Rough -In
Gas Line
S ke Dampers
S AS PART FAIL
tT RICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
PASS PART FAIL Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
SITE El Please call for reinspection RE: Unable to inspect - no access
Fire Supply Line 2 �t1
ADA - Approach/Sidewalk Date / ! Inspector ! Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL
6