Permit CITY OF TIGARD ELECTRICAL PERMIT
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= COMMUNITY DEVELOPMENT Permit #: ELC2012 -00623
• T f GARD • 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 10/30/2012
Parcel: 1 S135DB05100
Jurisdiction: Tigard
Site address: 11570 SW GREENBURG RD
Project: Piitz Subdivision: MILLER Lot: 4
• Project Description: (1) 200 amps or less
Contractor: OWNER Owner: PILTZ, KENNETH M
11570 SW GREENBURG RD
TIGARD, OR 97223
PHONE
PHONE: 503 - 484 -7362
FAX:
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 10/30/2012 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 10/30/2012 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
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 sus nded for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those r es re set forth in OAR
952- 001 -0010 through OA 952 - 001 -0090. You `�' 1 "^" �mayy oo bt t ai n a copy of the rules or direct questions to OUNC by calling 503.232.1987 r .80r�r 32 2 344.
Issued By: Permittee Signature: I .
J
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.
•
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard Received Permit No.: ,�,�
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Date/B : (0 30 tf y �JL��/� ... 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 p ale /D Other Permit:
TIGARD Inspection Line: 503.639 Date Ready /By: 0 See Page 2 for
Internet: www.tigard or.gov Notified /Method: ISM Supplemental Information
TYPE OF WORK PLAN REVIEW
❑ 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 ❑ 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
❑ I - and 2- family dwelling ❑ Commercial /industrial ® Accessory building amps for all other installations. buildings.
❑ Multi- family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE 1N3tORMA1'I,ON AND 'LOCATION 0 Additiott of itew motor load of ❑ 'A' °P" "I "1 -3"
Job no.: Job site address: 11570 S.W. Greenburg Rd. IOOHP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: 97223 ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: S.W. 94th Description I Qtv. I Fee. I 'total
New residential single - or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'l 500 sq. ft. or portion 33.92 I
Tax map /parcel no.:
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ti.)
Limited energy, multi - family 75.00 2
residential (with above sq. ft.)
Services or feeders installation, alteration, and /or relocation
200 amps or less 1 100.70 2
® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: amps to 600 amps 200.34 2
Name: Kenneth M. Piltz
_ 601 amps to 1,000 amps 301.04 2
Address: 11570 S.W. Greenburg Rd. Over 1,000 amps or volts 552.26 2
City /Slate /ZIP: Tigard, OR. 97223 Temporary services or feeders installation, alteration, and /or
relocation
Phone: (503)484 -7362 Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2 •
Owner installation: This instal - tiot is bei 9ide on property that I own which is not 401 amps to 599 amps 168.54 2
intended for sale- lease, rent, ' exch 'e, a■ t' to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature:
• ��� Date: 1 I "36 ', Z A. Fee for branch circuits with
❑ APPLICANT . ❑ CONTACT PERSON 7.42 service or feeder fee 7 42
each branch circuit
Business name: B. Fee for branch circuits wirhoni
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2 AS__Int Address: Miscellaneous (service or feeder not included)
Each manufactured or modular
Clty /SlCity/State/ZIP: 67,8 2
dwelling, service and /or feeder
Phone: ( ) Fax: : ( )
Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E-mail:
Sign or outline lighting 67.84 2
CONTRACTOR 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 (I hr min) 66.25/ hr
�`-� v' _ Investigation (1 hr min) 66.25/ hr
City/State/ZIP: Industrial plant (I hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed (%z hr min)
CC13 Lie.: Electrical Lie.: Suprv. Lie.: ELECTRICAL PERMIT FEES
Subtotal: 1 0 0 : 7 t ,
Suprv. Electrician signature, required: Plan review (25% of permit Ice):
Print name: Date: State surcharge (12% of permit fee): 1 ?._Og
TOTAL PERMIT FEE: ii a . l e
Authorized signature.
This permit application expires if a permit is not obtained within 180
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Print name: �./ Datel/' .5t • 12, 4 days after it has been accepted as complete.
I�� sri Number of inspections allowed per permit
I\ Building \ Perot its \EIX-Perin it A pp doc 07/01/10 440.461 ST( I I /05 /COM/WLR
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
n Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
❑ Vacuum Systcms*
❑ 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
n Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
n Medical
❑ Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
\Building \Permns \81.C- PermilApp doc 07/01/10