Permit Support Document y RECEIVED
1114 M, Building Division APR 2 5 2007
TIGARD Request for Permit Action CITY OF TIGARD
BUILDING DIVISION
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor X City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
44
V 0 1 ® Mailing Address:
.6-7; Q 7 A1 City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION. \
REFUND PERMIT FEES (attach receipt, if available). (7J0 PA, r / )
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: E Poo? - CQ A340
Site Address or Parcel #: /D57 5 04,3 69-- / 4- /So
Project Name: 4Efr/10/3
Subdivision Name: i3M- Lot #: IJl9-
EXPLANATION: t.),,d 1 I F EFL y �Ll H 1 1l a 2
Li.,31) F ,
0 - 7 - 7- 0 1 9 7
Signature: C , Date: I of ii /
■
Print Name: "1 6 6 l i. P.,_ 1) 'D kt
Refund Policy
1. The Director or Building Official may authonze the refund of.
a) any fee which was erroneously paid or collected
b) not more than 80% of the land use apphcation fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) 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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date '/j B ,_ yAp Rte to Bid: Admin: Date 7, B iUr�
Refund Processed: Date Al _ B Invoice Processed: Date B
Permit Canceled: Date SQ 7 B Zia' arcel Tat Added: Date B
Receipt # Date Method Amount $
I:\ Budding \Forms \RcgPemutAction.doc Rev 05/24/06
Electrical Permit Applic � � : ;'
�_ {{ 4(
I ,. FOR OFFICE USE ONLY
III City of Tigard Received
° 13125 SW Hall Blvd., Tigard, OR 972J 1 3 2007 Date/B Permit No _ '_Pik 062. ' Phone: 503 639.4171 Fax: 503.598.1% x ! Plan Review
Date/B Other Permit
I GA R D Inspection Line: 503.639.4175 a Date Ready/By
and -or. ov �, p _. X fig jl lam. S See Page 2 for
g g " Notified/Method:
Supplementallnformation
Internet www.ti
_ , -- TYPEIblirtvairkir ' I II A TMO' PLAN REVIEW
15.New construction Addition/alteration/replacement • Please check all that apply (submit 2 sets of plans w /items checked below)
❑ Service or feeder 400 amps or more 0 over three stones
❑ Demolition ❑ Other:
where the available fault current ❑ Mannas and boatyards
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings
El 1 - and 2- family dwelling ��otnmercial /industrial ❑ Accessory building less to ground, or exceeds 14,000 ❑ Commercial -use agricultural -
y g amps for all other installations. buildings
❑ Multi - family ❑ Master builder
❑ Other: El Fire pump 0 Installation of 75 KVA or
❑Emergency system. larger separately derived system
JOB SITE INFORMATION AND LOCATION
❑ Addition of new motor load of
Job no.: 1120 U 7 I Job site address: O ❑ "A ", "E ", "I - z ", "l - 3 ",
S 7S 1 Io0HP or more occupancy.
S p ' f n� ❑ Six or more residential units ❑ Recreational vehicle parks
City /State /ZIP: -7 / U ,, a a Q't 1 ❑ Health -care facilities ❑ Supply voltage for more than
❑ Hazardous locations 600 volts nominal
Suite /bldg. /apt. no.: I Project name: N ¢.r.1 C o w, ❑ Service or feeder 600 amps or more
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Fee. I Total I •
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft or less 145.15 4
Tax map /parcel no.: Ea add'I 500 sq. ft. or portion 33.40 1
Limited energy, residential
DESCRIPTION OF WORK (with above sq ft) 75.00 2
�e�`�O �� L energy, multi - family
I e- 1 G ay, S / 0, residential (with above sq ft) 75.00 2
Services or feeders installation, alteration, and /or relocation
200 amps or less 1 80.30 $'0 , 3 0 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps ) I // 106 85 `}2 7.'C 2
Name: . 401 amps to 600 amps 160.60 2
!dress: 601 amps to 1,000 amps I 240.60 2y-c). 6 C 2
Over 1,000 amps or volts 454 65 2
City /Stale /ZIP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66 85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133 75 2
Owner signature: Date: Branch circuits — new, alteration, or extension, per panel
A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee,
. Business name:
each branch circuit 6 65 2
B. Fee for branch circuits
Contact name: without service or feeder fee,
first branch circuit 46.85 2
Address: Each add'I branch circuit ) Ze 6.65 857 ,0 2
City /State /ZIP: Miscellaneous (service or feeder not included)
Each manufactured or modular
dwelling, service and /or feeder
Phone: ( ) Fax: : ( ) 90.90 2
Reconnect only 66.85 2
E-mail:
Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name: Boones Ferry Electric INC Signal circuit(s) or limited -
energy panel, alteration, or 75
Address: P.O. Box 628 extension. Describe: Page 2 /$ J 2
City /State /ZIP: Wilsonville OR 97070 Each additional inspection over allowable in any of the above
Phone: (503) 682 -4936 I - Per inspection 62.50
Fax: (503) 682 -7946
Investigation per hour (I hr min) 62.50
CCB Lic.: 88482 I Electrical Lie.: 3 -223C I Suprv. Lie.: 9-1 ( c Industrial plant per hour 73.75
Suprv. Electrician signature, required:, ' ELECTRICAL PERMIT FEES
Subtotal. � 7 99', S'
nl name: $ a>/1 CL) re I Date: cf -/3 - O 7 Plan review (25% of permit fee) t+ 3 7. 3 a
Authorized signature:
State surcharge (8% of permit fee): / 3 y. 94
TOTAL PERMIT FEE: 2 / 32 6 . g
Print name: Date: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
, I \Building \ Permits \ELC- PermuApp doe 05/23/06
• Number of inspections allowed per permit
440- 4615T(t 1 /05 /COM/WEB