Permit CITY OF TIGARD ELECTRICAL PERMIT
111 C COMMUNITY DEVELOPMENT Permit #: ELC2012 -00676
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/28/2012
Parcel: 2S 111 CC21300
Jurisdiction: Tigard
Site address: 10250 SW GREENLEAF TER
Project: Lawrence Subdivision: SUMMERFIELD NO.5 Lot: 271
Project Description: (1) 200 amp service - panel change
Contractor: FUZION ELECTRIC LLC Owner: LAWRENCE LIVING TRUST
21782 SW KRISTIN CT 10250 SW GREENLEAF TERR
ALOHA, OR 97006 TIGARD, OR 97224
PHONE: 503 - 528 -6033 PHONE:
FAX: 866- 284 -0482
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 11/28/2012 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 11/28/2012 $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 ot 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 ork is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility ion enter. o rules. are set forth in OAR
952- 001 -0010 through • . - 952 -' r r r • r. Y •-u may obtain a copy of the rules or direct questions to OUNC by cal g 503.2 .1987 or 1. 0.; 3 .2344.
II Issued By: � /L � �= Permittee Signature: .170111 1 Ai.d3+
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 RE C,� D holz orFICH I SE ONLY
RECEIVED
City of Tigard Received Date/B : // / ag Permit No.&2 1 f/ — 006 7 .
4 ' • 13125 SW Hall Blvd., Tigard, OR 97223 M/ ' q $ O 12 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 " UM � p� Date/B : Other Permit:
TI G A RD Inspection Line: 503.639.4175 3 OF Date Ready/By: turie�� H See Page 2 for
Internet: www.ti ardor. ov CITY Notified/Method: P Supplemental Information
TYPE OF, DINGDIV ISION 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
0 _1- and 2- family dwelling ❑ Commercialindustrial ❑ 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 ", "1 - ", "1 - ",
Job no.: Job site address: 2-50 5� 6iy'( toi ,,i/ Six o o erre. Recreational vehicle parks.
City/State /ZIP: ` 5 ,,, r A., ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qtr. I Fee. I Total i •
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'I 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
1 (ilt e, 1 Clnan5e residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation _
200 amps or less C 100.70 OD .70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
Name: 401 amps to 600 amps 200.34 2
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State /ZIP: relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 1
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 sale, 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 signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: . L i ` r ' , e `.E-..,ri _ B. Fee for branch circuits without
service or feeder fee, first
Contact name: e _4\— t yk branch circuit 56.18 2
^--� A �, p Each add'I branch circuit I I 7.42 I 12
Address: 1' st l g / - Miscellaneous (service or feeder not included)
City/State/ZIP: A 1 v - kG criZ 9 " coo Each manufactured or modular
dwelling, service and/or feeder 67.84 2
Phone: (5-05) 52 g b 0-33 / Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: b re- if 0 . L7. Tv e f e c -iy/ c -C (j•'Y1 Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
panel, alteration, or extension. Page 2 2
Business name:
50 Each additional inspection over allowable in any of the above
Address: Additional inspection (I hr min) 66.25/ hr
Clty/State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is
o specifically list (%z hr min) 90.00 / hr
PB Lie.: rr i 7q ctrical Lie.: C,59 Suprv. Lic.: 552 .' ELECTRICAL PERMIT FEES
/ Subtotal: 160."7
Suprv. Electrician signature, required :L
Plan review (25% of permit fee):
Print name: ' . -- - "'r6 1 Date: 1/24/ z— State surcharge (12 % of permit fee):
� TOTAL PERMIT FEE: 1 12, ,11
Authorized signature: � 0-^-----____ This permit application expires if a permit is not obtained within 180
+ �� D ate: �/ t days after it has been accepted as complete.
Print name:
<g -f t . ( rr / (/23 12— Number of inspections allowed per permit.
11Building 'Permits \ELC- PermitApp.doc 07/01/100 440- 4615T(I1/05 /COM/WEB