Permit I
,'° s'� Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 Planck/Rec. #
At' � Permit # . -L-C 95 --00
Vii' "" ,
I Phone (503) 639 -4171
"'�'` Ail
FAX (503) 684 -7297 Date Issued C��d -6 -)
CITY OF TIGARD TDD No. (503) 684 -2772 Issued by
Inspection (503) 639 -4175
i 1. Job Address: 6 —s 5 e2 `' 0 4. Complete Fee Schedule Below:
Name of Development :1 Pect172i1 Number of Inspections per permit allowed
Address q5 711, 14. t 5 Q, `P.D. Service included: Items Cost(ea) Sum
City/State/Zip T ei c , 57 7'2 3 4a. Residential - per unit 4
1000 sq ft or less $110 00
-
Name (or name of business)_ 'L ... Each additional 500 sq n or
portion thereof $25 00 1
Commercial Residential ❑ Limited Energy $2500
Each Manuf'd Home or Modular 2
Dwelling Service or Feeder $68 00
2a. Contractor installation only:
4b. Services or Feeders
Installation, alteration, or relocation -�c� 2
Electrical Contractor �✓ /MN, a4 Flee-iv/4 200 amps or less $60 00 / ZO4 2
Address /d lee . ,ef,a4 201 amps to 400 amps $80 00 2
City c per) - et1}n State 0 Zip 57 1/Li 401 amps to 600 amps $120 00 2
6d 601 amps to 1000 amps $180 00 2 ■
Phone No. 7.--3 '{ (0S Over 1000 amps or volts $340.00 2
Contractor's License No. a z Reconnect only $50.00
Contractor's Board Reg. No. - 37 --5-'q G 4c. Temporary Services or Feeders
Installation, alteration, or relocation 2
Signature of Sup Elec'n 1 t�.'Y`t�� 200 amps or less $5000 2
License No. 51 g 4-..S Phone No. 201 amps to 400 amps $7500 2
401 amps to 600 amps $100 00
Over 600 amps to 1000 volts
2b. For owner installations: see 'b' above
4d. Branch Circuits
Print Owner's Name New, alteration or extension per panel
Address a) The fee for branch circuits with
City State Zip purchase of service or feeder t'y,� 2
Each branch circuit (O $5 00 /3 W.
Phone No. b) The fee for branch circuits without
The installation is being made on property I own which is purchase of service or feeder fee. 2
not intended for sale, lease or rent. First branch circuit $3500 2
Each additional branch circuit $5 00
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or irngation circle $40 00 2 - Each sign or outline lighting $40 00
Signal circuit(s) or a limited energy 2
Please check appropriate item and enter fee in section 5B. panel, alteration or extension $40 00
i 4 or more residential units in one structure M inor Labels (10) $10000
Service and feeder 225 amps or more
System over 600 volts nominal 4f. Each additional inspection over
Classified area or structure containing special occupancy the allowable in any of the above
as described in N.E.C. Chapter 5 Per inspectio t35 00 -
Per hour $55 00
-
In Plant $55 00
Submit 2 sets of plans with application where any of the above
apply. Not required for temporary construction services. 5. Fees:
NOTICE 5a. Enter total of above fees $ /y®.
5% Surcharge (.05 X total fees) $ 2.-2,6D
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5b. Enter 25% of line A for
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Review if required (Sec 3) $
A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal $
COMMENCED. ❑ Trust Account #
$ ,cam
Balance Due $ 1 9 6 460
wortko l .NWcpm app