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Permit
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \/ 0 1 0 UPI ■ Request Permit Action 00/,-/q 1 ; , , A 1: 1 1 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 El Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) /JO PAY/'1 -Nr5 HA t) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 1 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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: Ike- o`er 1/ - DO 7 ill Site Address or Parcel#: 7a75 0,1-it—o-lour7-F er- 2/eu Project Name: '/j(pf}2.b l 4,J(o'I o f,L.f Subdivision Name: Lot#: EXPLANATION: 17;16 Qwi,T P,,1/4-t,ITir Sy 4kd.JJ-,TTcT. 4-r- 1-4-r A- bA-TC, CO n.>f/Lr4-e_ro, - .ca.J Mr 17-E 1) f+AOu C,4-77c n.) cz/'� , tJ£ Puziir r eat Arc 7) S Gl G c;20/a- DO J•g(i. &)( / /w'.(!) °► I!J`✓PiCTf D zi,jbei2. FEe_'.k,lil-oo 44 Signature: £ Q.. ,,�,� Date: 1/A/11 y Print Name: ' T-)f,g 61 Q_ f}7j,4tit S k 1 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 b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 2-4 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Dat• if I hi EMS/ Rte to Bldg.\dmut: Date//,...2:4//y By gr% Refund Processed: Date /9" By i■•'• Invoice Processed: Date By Permit Canceled: Date / gaily By 4" Parcel Tag Added: Date By Receipt# Date Method Amount$ I:\Building\Forms\RegPemmitAction.doc Rev 05/25/2012 Electrical Permit Application i FOR OFFICE USE ONLY City of Tigard C ti%\\ Received h� �� r Permit No.: f—, ` I_�72? 13125 SW Hall Blvd.,Tigard,OR 9 223 Y S) Plan Review vv = Phone: 503.718.2439 Fax: 503.598.1902) - G(4GPS�O� Date/By: Other Permit:(NA Ppo('-0037/ T I G A R[� Inspection Line: 503.639.4175 �T t� Date Ready/By: orris ® See Page 2 for Internet: www.tigard-or.gov AS` 1- CN Notified'Method: Supplemental Information TYPE OF WOIi *- PLAN REVIEW El construction ❑Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w items checked below): p� -fir ❑Service or feeder 400 amps or more ❑Building over three stories. ❑ Demolition COI Other: y' 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 ❑ 1-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 JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system. ❑Addition of new motor load of ❑"A"•"E","1-2","1-3", 100HP or more. occupancy. Job no.: Job site addres � !>'t/f"4� w ti.i.„6 ❑Six ore residential units. ❑Recreational vehicle parks. City/State/ZIP: %8o ealth care facilities. 0 Supply voltage for more than �j t0 ❑Hazardous locations. 600 volts nominal. Suite/bldg./apt.no.: Project name: i %`QA'0 TZ 31t Sti,k 1 ❑Service or feeder 600 amps or more. eft 471,4_ C j(,fil/ d FEE SCHEDULE Cross street/directions to job site: Description I Qty. 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'l 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 3 -e L� i O_y-} 1 ;i-) ) ( '1�},(l h ` '7 L)i'--G, 5 residential(with above sq.ft.) 1 Y 1 _! / Services or feeders installation,alteration,and/or relocation �( ( ) {��1 \+( (�•) _}1 (-x 1 S ) 1 200 amps or less 2r15) 100.70 2 4 ❑ PROPERTY OWNER R TENANT 201 amps to 400 amps 133.56 2 Name: 1. i. 401 amps to 600 amps 200.34 2 V' ((�L V b\-f-1"`":0— `�- V` le-_S 601 amps to 1,000 amps 301.04 2 Address: ''1,0 lr e. (1_j D L",11,C O2 '1 i,,tp F Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or City/State/ZIP: I ex..v i �e [� 91,1006:2 relocation y )L� 2(9v Lj 1 200 amps or less 59.36 1 Phone:(`71 ✓ Fax: 1( ) �� •�j�� 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 p � 'TONTACT PERSON 7.42 2 above service or feeder fee, (j�APPLICANT each branch circuit Business name: B.Fee for branch circuits without (' l��Q- 'j L '` k r __ j`-1-,A C(S service or feeder fee,first Contact name: I / iJ�r,>�p branch circuit 56.18 2 v "l '" t Each add'l branch circuit 7.42 2 Address: 7o 4 4/ 01 /( ('.!,/'•"i1/ Miscellaneous(service or feeder not included) City/State/ZIP: // 'tt 7 1 Each manufactured or modular 67.84 2 ty (i(Yf V 1 C? 9 2 bit/ dwelling,service and/or feeder Phone:(a rI) c i/, Z c t.l s Cr ax::r)(') 'f y _ 4�S ) Reconnect only 67.84 2 E-mail: �� f Pump or irrigation circle 67.84 2 c2 , '� -. L" .I (i,v1 Sign or outline lighting 67.84 2 r a �. =. : CO CTOR 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(1 hr min) 66.25/hr Investigation(1 hr min) 66.25/hr City/State/ZIP: Industrial plant(1 hr min) 78.18/hr Phone:( ) Fax:( ) Inspections for which no fee is 90,00/hr specifically listed('A hr min) t CCB Lic.: Electrical Lie.: Suprv. Lie.: ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: a Subtotal: Plan review(25%of permit fee): Print name: Date: State surcharge(12%of permit fee): TOTAL PERMIT FEE: Authorized signature: This permit application expires if a permit is not obtained within 180 Print name: Date: days after it has been accepted as complete. Number of inspections allowed per permit. 1:\Building\Permits\ELC-PermitApp.doc 07/01/10 440-4615T(11/05/COM/WEB 2 0 ,. � A Q S�c' X 3c 3 a' a ©� 2 of 2 tj --1 'Cinr 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 ❑ Garage Door Opener* ❑ Heating,Ventilation and Air Conditioning System* ❑ Vacuum Systems* ❑ 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 ❑ Boiler Controls ❑ Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* Medical �❑ Nurse Calls ❑ Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other Total number of commercial systems: 2. *No licenses are required. Licenses are required for all other installations 1:\Building\Pecmits\ELC-PermitApp.doc 07/01/10