Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
IN ®1
Request Permit Action 42/-g %
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Ri City Staff
(check one)
REFUND OR Name: N/
INVOICE TO: (Business or Individual) �-
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
N CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ei.. A D / 3 - OD a 37
Site Address or Parcel #: 4/
Project Name: //i //• #i f2 /A y E_
Subdivision Name: ( Lot #:
EXPLANATION: (I ,e . 4TH ,3 f220R_
o�CE
6-2 9.6/3 -0o
Signature: CL)04.6 Date: 94
Print Name: l ) f 4 j 2- 47D /9-4 15k /
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 onginal Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date 27 / 3 B Rte to Bldg Admin: Date : 3 .3 By —
Refund Processed: Date if/ ' By Invoice Processed: Date By
Permit Canceled: Date Vjj 3 By ' Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPemvtAction.doc Rev 05/25/2012
CITY OF TIGARD ELECTRICAL PERMIT
1 Per
• COMMUNITY DEVELOPMENT Permit #: ELC2013 -00237
1 3125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/29/2013
T I t_r A R O 9 Parcel: 1S136AB03800
Jurisdiction: Tigard
Site address: 10008 SW 71ST PL
Project: Boomer Subdivision: LOCUST TERRACE Lot: 5
Project Description: Replace electrical panel
Contractor: RITE WAY ELECTRIC Owner: BOOMER, ELAINE CLEMES & RALPH DA
2904 THREE LAKES RD. SE 10008 SW 71ST PL
ALBANY, OR 97321 TIGARD, OR 97223
P
PHONE: 707- 342 -6002
PHONE: 541- 926 -0504
FAX: 541- 926 -2656
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 04/29/2013 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 04/29/2013 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in acco • , • .- with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATT ION: Oreg• law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001-0 10 through OAR 95 • • .: You may obtain a copy of the rules or direct questions to OUNC by calli ...Joie . 2.1987 or 1.800.33 .2344
Issued - : ! �� . i Ls - Permittee Signatur$ Sr i ,/ •
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' (4 0 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.
Apr 2513 08:25a WENDY RWE 503 -651 -1496 p.1
APr.25. 2013 10 :11AM No.7515 P. 1/2
Electrical Permit Application RECEIVE r ,,,, r„ ill , I •. r „t 1
City of Tigard 5 2 Q13 , n a 4i' / Q0 norm itNo.: jLC,�d —.00,2.3,
II w 13125 SW H211 HPvd_, T igard, OR 97223
g Ph oat 503.118 2439 fax: 503.598.1960 D en Revtew Other Permit:
, ,_ „ r. , inspection Line: 563.639.9175
CITY OF TIGAR : ludt: ad Ste Pap for ,
Internet! �wvwtisard or.gav FUII.DING DWISI , "�"' ] �`"° Supplest total Worm slim.
TYPE OF 'WORK - • PLAN REVIEW
❑ New construction 5 Addition /alterationfreplaccarett Please chock all r apply faubmitZ sea of Maas w1 «ems checked below):
El Demolition Ej Otherr: O where available c 0 M a r i ing nd boayards. ies.
_ ❑ bleina, and boatyards.
CATEGORY OF CONSTR[•7t- [1oN : _ exceeds 10,000 amps at 150 volts or 0 Floatint buildires.
len re 1- and 2- family dwelling [I Cominerciai/ ndustria] 0 Accessory building sorpo aO°"d or i on,. ❑ b o ldeam . ar• agricultural
g amps far all other iretalLrioo :_ build.'ags
❑ Multi- family ❑ Master builder 0 Other ❑Fire pump. ❑ laualiaraaof75 KVA or
J08 SITE INFORMATION AND .LOCATION
�,TfoN - 0 Emergency system. larger separately derived tyateee.
❑ Addition anew rector bed af 0 "A ^,R'.'1- 2 ",9-3 ^,
Job no.: Job site address:/000 ) r.?.is— Pl4c.e. loollp Of mac. occupancy. D six or more rmicea,ial usUcr, ❑ Recreational which yadra.
City/State/ZIP: % i 44 OVE • '7 4) ,Q 3 ❑Heuh-care facilites. ❑ Supply voltage for more than
❑ Haaadous locations. 600 volts nominal.
Suite/bldgJapt. no.: Project name: ,` • t✓ ❑ Service cc' feeder 600 amps or more.
YEE SCIDULE .
Cross street/directions to job site: tt,.aa;,v.. ' 1 oat. I parr I tool
New residential single- or multi- fierily dwelllarg unit.
Includes attached garage.
Subdivision: Lot no.: 1,000Sq•I 168.54 4
It.
Ea. add'! 500 sq. ft, ur portion 3192 1
Tax map/parcel no.: _Limited enerp, residential
DESCRIPTION OF' WORK . jwith above sq. ft.)_
75.00 ,_ 2
�/ /� � limited energy, multi•faanity 75.00 2
9 e_ p �CR— des �F'iri tit- Pa.() e . / residential (wish above sq, ft.) _
- Services or feeder Installation, alteration, and/or relocation
200 amps or leas j 100.70 /02:w 2
pc PROPERTY OWNER - . • 0- TE).(APIT • . 201 srrlps to 400 amps 133.56 2
—
Name: 40i amps to 604 amps 200.34 2
Xm4 / . ∎ 603 amps to 1,500 amps 30].04 2
Address: Over 1,000 amps Or vole 552.26 2
CitylScetlelZlP: o7 p. PC Temporary services or feeders i aatalls dos. alteration, aod/o
relocation
Phone: . 317' _ i ) aZ pax: ( ) 20C unpa or less 59.36 1
Owner installation: This installation is being made on ro that 1 Own which is not 201 amps to 400 amps ' 125 2
P P5 401 amps to599 amps 1 intended for Sale, lease, rest, or exchange, according to ORS 447, 449, 670, and 701. Branch circuits new altentton or extension, panel _, 2
OWncf Signature: Date: A Pee for brench Circular with .
-
r1:j ApPITCAN? • - . 1.. - - 0 COtv7`At r,il�leli.§br aboveservi�e
. 7.42 2
r-_ each branch circuit
Business • n : 8. Fee for branch circuits widrora -
semi as or feeder fee, fiat
56.18 2
Contact name: - branch circuit
Each add'l branch circuit 7,42 I 2
Address:
MIscdlaneoua (service or feeder not included
City/ State /ZIP: Each manufactured «modular 67.84 2
dwelli�, service and/or fonder
Phone: ( ) reim Reconnect only 67.64 2
-mail: Pump or irrigation circle 67,84 2
Sign or outline I ig3tbng 67.84 2
COw'4TltACTOj ' Si circuits) or limitadsnergy 1
Business name: t " VAY r (0 ( - 1 - #- C < Para, atoenubon, or extension. Page 2 2
Each additional inspection over allowabk to any of the abov
Address: 411 • , . _ - J `• _ �Additionat inspection (1 hr Min) 66,25/ hr
City /State/Z3P: / r t1 S Investigation (1 min} 6625! ht
ANP AM � �— oC Industrial plant (1 Iv min) 78.18/ hr
Phone: ( ) 'e , to ,.- a, S. FM; (5i j) 9 l • - Inspections for which no fee is I 90.00 / hr
specifically listed (34 by min) i
COI Lie. :260 Electrical laic.: • • _ s . rv. ie.: 3 a q - 5 • l cnueAL PPHMTT FE>�
Suprv. Etectri ° 1 • r , required:
��:/ Subtotal: /Q�J,'7�(3
_ . - Plan review (25%ofpermit fec):
. Print name: } ` - Dale: State surcharge (12% o permit fee);
drt� e y - a te r A2.08 4 ,14 _ , Authorized signaler ,'Sm TOTAL PERMIT MEE /AZ )
t`'i� ��I♦ rhi% Wm-ft appEf nriro &vi Ka permit a rot ohm iced within] 0
? days afros alias been acts 0.1 u
r m
Pont name: 6 FA/ F £/'9/` S Date: Li LI —/ J �eaa