Permit CITY OF TIGARD ELECTRICAL PERMIT
IN 6 : COMMUNITY DEVELOPMENT Permit #: ELC2012 -00522
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 09/11/2012
Parcel: 1 S 136CB02400
Jurisdiction: Tigard
Site address: 11160 SW 82ND AVE
Project: Coolman Subdivision: RANCH VALLEY Lot: 5
Project Description: Installation of ground rods due to replacement of water service.
Contractor: OWNER Owner: COOLMAN, HERBERT R & ENOLA MAE T
11160 SW 82ND AVE
TIGARD, OR 97223
PHONE
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Reconnect Only 09/11/2012 $67.84
Specifics:
1 ea 12% State Surcharge - 09/11/2012 $8.14
Electrical
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $75.98
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 w 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 I. • uires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 01 -0010 thr•ugh OAR 952 -r r -00 - 0 'ou may obtain a copy of the rules or direct questions to OUNC by calling 503.22.1987 r 1.800.332.2344.
-
l ed By: _ �� Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on prope I ow wh h is not intend for sale, lease or rent.
i 9/ // 2
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.
Electrical Permit Application FOR OFFICE USE ONLY
Received ��� ,. // wI t
City of Tigard Date/B : Permit No.: r —c
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
C Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:
TI G A It D Inspection Line: 503.639.4175 Date Ready/By: lulls: ® See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ New construction Addition/alteration/rWascultent, 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
Egi 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 ",
,. / p Np ^ 100HP or more. occupancy.
Job no.: Job site address:
I I I � -VV !/ Z A VV ❑ Six or more residential units. ❑ Recreational vehicle parks.
City/State/ZIP: T/ AR D ie1 • 972,23 ❑ Health-cities. za do use ocaiis. ❑ 600v nomi alr more than
i� ❑ Hazardous locations.
Suite/bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
p FEE SCHEDULE
Cross street/directions to job site: T / pLE _ Description I Oh'. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: RA AL C.g V A"t,Gi V Lot no.: S 1,000 sq. ft. or less 168.54 4
Ea. add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi- family 75.00 2
Vi-- f&FR I LA L 2cD u R /D residential (with above sq. ft.) _
Services or feeders installation, alteration, and/or relocation
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: fri�RZ Z--- CD _ni 601 amps to 1,000 amps 301.04 2
Address: 11 I Con C vii 7r 2 ALp A V_ Over 1,000 amps or volts 552.26 2
City/State /ZIP: TV- g• Q O R 9722 Temporary services or feeders installation, alteration, and/or
7 relocation
Phone: (53) 631 - 472. 2 Fax: ( ) 200 amps or less 59.36 I
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 s e, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, per panel
Owner signs re' Date: 7 -I I - /2 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
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)
City/State/ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only / 67.84 47 2
Pump or irrigation circle ( 67.84 2
E -mail:
Signor outline lighting 67.84 2
CZnit) OJ�VTRA OR 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 (I hr min) 66.25/ hr
Industrial plant (l hr min) 78.18 / hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed (%A hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES / ^ Q
Subtotal: Ca 7 • 6y
Suprv. Electrician signature, required: Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): g T
TOTAL PERMIT FEE: "7 K. 99
Authorized signature: This permit application expires if a permit is not obtai within 180
Print name: Date: • days after it has been accepted as complete.
Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 07/01 /10 440- 4615T(I1 /05 /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:
El Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air•Conditioning System*
❑ Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
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
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.055 (4))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
1 I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
/5 I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
Prin Name of Permit Applicant
9 -11 1 2—
Sign ture of Permit Applicant Date
. Permit #: ` 5.)-r)
0 �w g? - � 1-) r ,
Address: !114
Issued b Date: 94/49
This Copy for Permit Offices