Permit Community Development RESTRICTED ENERGY ELECTRICAL APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 PERMIT # FCR 9S 0 I a, a
4 4 ;t Phone (503) 639 -4171
. I I� FAX (503) 684 -7297 DATE ISSUED 9- J?- 9s
�
� `- TDD No. (503) 684 -2772
CITY OF TIGARD Inspection (503) 639 -4175 ISSUED BY dp. r/e t Sc1 ir,7dI
PLEASE COMPLETE ALL SECTIONS
1. LOCATI P N • F INSTALLAT� N , / 4. TYPE OF WORK
Add- t / �� RESIDENTIAL — Restricted Energy Fee $40.00
i.g/A. (FOR ALL SYSTEMS)
City State Zip Check Type of Work Involved:
PRMITS ARE S NOT STARTED WITHIN S 180 DAYS OF ISSUANCE ORDF WORK AND
SUSPENDED FOR
OR ❑ Audio and Stereo Systems
180 DAYS ❑ Burglar Alarm
2. CONTRACTOR APPLICATION
❑ Garage Door Opener*
' ❑ Heating, Ventilation and Air Conditioning System*
Contractor / Ay Type / . ! i it - ❑ Vacuum Systems* .
Address �Q! /V (: ' A' .(-Q , ❑ Other
Date —4=5"--,5 COMMERCIAL — Fee for each system $40.00
/ (SEE OAR 918 - 260 -260)
Property Owner
Check Type of Work Involved:
Contractor's Board Reg. No. r ❑ Audio and Stereo Systems*
IL c 3 ❑ Boiler Controls
(
Phone # C
❑ Clock Systems
3. OWNER APPLICATION ❑ Data Telecommunication Installations
/ ❑ Fire Alarm Installation
,V ❑ HVAC
Print Owner's Name Phone No
❑ Instrumentation
Address ❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
City State Zip ❑ Medical
This permit is issued under OAR 918 - 320 -370 This applicant agrees to make only ❑ Nurse Calls
restricted energy installations (100 volt amps or less) under this permit and to do the ❑ tdoor Landscape Lighting*
following
1 Only use electrical licensed persons to do installations where required (Certain Protective Signaling
residential and other transactions are exempt from licensing. These have ❑ Other
asterisks( *). All others need licensing).
2 Call for an inspection when all of the installations under this permit are ready
for inspection at 503- 639 -4175.
❑ Number of Systems
3 Purchase separate permits for all installations that are not ready for inspection
when the inspector is out to inspect under this permit ' No licenses are required Licenses are required for all other installations
4. Assume responsibility for assuring that all corrections required by the inspector
are done, and
5. Assume responsibility for calling for a final inspection when all of the corrections 5. FEES
are completed.
The person signing for t 's per it must be the applicant or a person a. Enter Fees $ 44-0)
authorized to•. h: at • 'cant.
40 bi b. 5% Surcharge (.05 x total above) $ 0- e
Signature � TOTAL $ 44' �/ V
Authority if other than applicant
ENERGAP.CHP