Permit :I • o Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) 1\)//4.-
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
ip .. CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel ermit).
Permit #: Ekc Aoo 8 r
Site Address or Parcel #: /149940 N/`►1 a , 4 G
Project Name: ,54 2u
Subdivision Name: 4 Li 361 lJ-&r, Ai. A Lot #: /e)
/l
EXPLANATION: eP_ 4-rrt) 10 C.IgIGO/G — J 71 ,,9 1 5
�t5` -D,aTO
Signature: -...) CLJ.ul9- Date: $ /
Print Name: ----1- 1 ) ) P. P? N A J
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) 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 Sys Admin: Date By Rte to Bldg Admin: Date Af /9 - By ,VO /- LES
Refund Processed: Date A/A7 By Invoice Processed: Date By . P-0-72_ /18
((
Permit Canceled: Date !! 70.1.- By ,; "' • arcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
8/01/2008 FRI 13:29 FAX 5036781108 Bear Electrlc,Inc. Q001/002
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• Electrical Permit Application FAXIE FOR OFFICE USE ONIV
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City of Tigard Received
Permit No.:
• , " 13125 SW Hall Blvd.. Tigard, OR 97223 A I J 1: " 0 1 : tit1figR iew
• ' ° Phone: 503.6394171 Fax: 503.598.1960 Date/By: Other Permit:
TIGARD
Inspection Line: 503.639.4175 Date Ready/By: las: Fa See Page 2 for
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Internet: www.tigard Notified/Method: Supplemental Information •
. '..:......... ::' .1 ...., .1 ': - .4; ' •. ‘ .•:: : :: : :•; ; : . '.: ':i. ...:::1 : .;;AP:#.., : ;crE4:::*PR*!": ; :• —.• .1,-, .--, S•21114:ti:::.);•::,:1::*.•1 ::::::•;
0 New construction 4;31Addition/alteration/replacement Phase check all that apply (submit 'sets of plans w/items checked below):
0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
exceeds 10.000 amps at 150 volts or 0 Floating buildings
.. :: . :: . .;,:: : :::..7 . .. ; i: .. 1.:':: , : : ::: , .; , : .. legM0:44 - .000* . .. ; :Z : : ; ::!..: : 4;7 .
— " less to ground. or exceeds 14.000 0 Commercial-use agricultural •
• sgi- and 2 dwelling 0 Commercial/industrial 0 Accessory building amps for all other installations. buildings. .
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0 Multi 0 Master builder 0 Other: 0 Fire pump. . 0 Installation of 75 KVA or
: .. ' - • : ' • . •y• " . .... •:,:: • • ,.....;!..;:,„...: ,., DEthmency system. larger separately defived system.
• occupancy.
Job no.: Job site address: lit?f4, s iAj si,„,,,,, I ap it 1 _ 100HP 07 MOM.
ir 0 Six ofmore residential units. 0 Recreational vehicle parks.
City/State/ZIP: T.:()■ I . 612,_ i 7 Ig_c_i 0 Health-care facilities. 0 Supply voltage for more than
0 Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: 4 Project name: / ' 0 Service or feeder 600 amps or more.
•Wl••■■...-7-Li, t": 2:; .■ : ::: ' : . : : : ::: : : :Nii;IR. : .S : tr*Witt.kliETIt:^0,■ : ; . .` " .
Cross street/directions to job site: " DesaiptIon i o„,. r - Fee ) retest
New residential single- or multi-family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft or less 145.15 4
Ea. add'l 500 sq. ft. or portion 33.40 1 •
Tax map/parcel no.: •
.. .,,. . Limited energy, residential •
'ler.,;::.:T.':•:::-WcatEr.. WS00ijerCO51.041,0C.W*Vg0/14::;liig:1-'gl,e; Limited energy, multi-family 75.00 2
A_ (with above "I• ft') 75.00 2
AciA. 409104, ' 1 , ILL. i Aff671.4- A i
1,4"
- ) residential (with above sq. ft)
) Cer1Je/Li f3±
Services or feeders installationolteration, and/or relocation
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/1)20 1 r 200 amps or less 80.30 2
..: : ... ...- ci p):0:041* ... '..„!..., ..." ::: ...':: j',.. ' ::-... 201 amps 10 400 amps 106.85 2
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401 amps to 600 amps 160.60 2 •
Name:
601 amps to 1,000 amps 240.60 2
Address: Over 1.000 amps or volts 454.65 r. 2
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) I 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
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Own Branch circuits - new, alteratioth or extension, per panel
er Date: signature:
A. Fee for branch circuits with
..CV*iii'410': if*40.*:::s.:;,.::.b. above ser or feeder fee 6.65 2
each branch circuit
Business name:
• B. Fee for branch circuits
hout d / service or feeer fee,
Contact name: .1),..eA.IA:A.„ wit 46.85 rg 2.5" 2
first branch circuit I •
Address: . .., u ,....... e.„. Each add'l branch circuit a 6.65 I `S,3C 2
Miscellaneous (service or feeder not included)
City/State/ZIP) Each manufactured or modular
90.90 2
dwelling, service and/or feeder
Phone: (52)3 ) 6 7 _ Li O 0 1. g I Fax: : ( )
• Reconnect only 66.85 2
E-mail: Pump or irrigation circle 53.40 2
.:..,.-... ... .•. : .. - ,"7,..;.. .1 ..•... ':" .;',..:.; ptiritgArto)tTh.:.:g.::....; ,.. • .. ; ' , Sign or outline lighting 5340 2
Business name: \Q ..A. c d..1 \ v. ‘ Signal circuit(s) or limited-
energy panel, alteration, or
Address: -O. c 3Ct)C\ • extension. Describe: Page 2 • 2
City/State/ZIP: Dory.) \c Cyc. , (...102C-) Each additional inspection over allowable In anyof the above
Per inspection 62.50
Phone: ( 0 ., • 1 ‘• _ Fax: (5co 'I - ( 1 Cj
Investigation per hour (I hr min) 62.50
• CCB Lic.: -2_0cl kg Electrical Lie.: ti -icil Suprv. Lie.: Li 8 8 1 S Industrial plant per hour 73.75
Suprv. Electrician signature, required: .. . ■ (? -• % ‘.N1 .. ..#4iO4001M!*..10 1 )g.:• : '• : •::' .- . • .
Subtotal: 0 . i C
Print name:S .t p291:3 ec t, Q , Date: -- "CA , Plan review (25% of pennit fee):
State surcharge (12% of pennit fee): , 0... ...
Authorind signaturt: , TOTAL PERMIT FEE: • ? , 3(
Print name: Date: This permit application expires if a permit is not obtained within 180
days after it has been accepted as Complete.
- • Number of inspections allowed per permit.
1: kluildinc Pcrmns ELV•PanmApp.doc 05 21 06 44046151111 05 COst WEB
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