Permit CITY OF TIGARD ELECTRICAL PERMIT
S COMMUNITY DEVELOPMENT Permit#: ELC2014-00138
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/24/2014
Parcel: 1 S 134CA03200
Jurisdiction: Tigard
Site address: 11920 SW NORTH DAKOTA ST
Project: Fannie Mae Subdivision: BURLWOOD NO.2 Lot: 5
Project Description: Reconnect Only.
Contractor: Owner: FEDERAL NATIONAL MORTGAGE ASSN
BY CITIMORTGAGE INC
1000 TECHNOLOGY DR MS314
OFALLON,MO 63368
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Reconnect Only 03/24/2014 $67.84
Specifics:
1 ea 12%State Surcharge- 03/24/2014 $8.14
Electrical
Type of Use: SF
Class of Work: OTR
Type of Const:
Occupancy Grp:
Total $75.98
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 accordance 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. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.19987 or 1.800.3332.2344_
Issued By: < �' — Permittee Signature: Q C�r¢1�'Zr�Le✓1
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 R1:J1r1J1 1 Y FOR OFFICE USE ONLY
Received
City of Tigard
Date/By: 3'/ j /1/ / - Permit No.: -� ,-� t4-j _ 40138'
13125 SW Hall Blvd.,Tigard,OR 97223 MAR 2 4 2014 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:
Inspection Line: 503.639.4175 funs: ® See Page 2 for
l I ci� t a CITY OF TIGA otifieeth d:Internet: www.tigard-or.gov
sJ-'r- Supplemental Information
TYPE OF WOR ' ' .Ti t ' PLAN REVIEW
❑New construction ❑Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked below):
L ❑Service or feeder 400 amps or more ❑Building over three stories.
El Demolition ]Other: El t°_C 41 ((Ca aQ C L i 1 t L i T 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
g1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 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",
1 J� 100HP or more. occupancy.
Job no.: Job site address: 1 1 -I Z U C)(!U( Cly1/1 [ k.Sfro Six or more residential units. ❑Recreational vehicle parks.
City/State/ZIP: `R/,ar ` 0 i Cj'j Z- ❑Health-care
Hazardous locations. ❑Supply voltage for more than
"1 2 600 volts nominal.
Suite/bldg./apt.no.: J Project name: ❑Service or feeder 600 amps or more.
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
Tax map/parcel no.: Ea.add'I 500 sq.ft.or portion 33.92 l
Limited energy,residential
DESCRIPTION OF WORK (with above sq.ft.) 75.00 2
n //�� Limited energy,multi-family 75.00 2
CIA G-l-r(e Girt/ l�C C7 n no (}" 27cpec il On residential(with above sq.ft.)
Renewable Energy ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
V PROPERTY OWNER I ❑ TENANT 200 amps or less 100.70 2
201 amps to 400 amps 133.56 2
Name: ' 1 1f-% n l Q... Alta-_ 401 amps to 600 amps 200.34 2
Address: 601 amps to 1,000 amps 301.04 2
Over 1,000 amps or volts 552.26 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
Phone:( ) I Fax:( ) relocation
200 amps or less 59.36 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168.54 2
Owner signature: Date: Branch circuits-new,alteration,or extension,per panel
❑ APPLICANT I ] CONTACT PERSON A.Fee for branch circuits with
above service or feeder fee,
7.42 2
Business name: bey ii<k ire__, LA-La/A.044 1t f �t�� each branch circuit
B.Fee for branch circuits without
Contact name: service or feeder fee,first 56.18
r& �/1 Y^1�'1/- branch circuit `
Address: 33(o psi E CAt u rvl/ a #13 0) Each add'l branch circuit 7.42
City/State/ZIP: ^vn` /; /- Miscellaneous(service or feeder not included)._
Sra� OOSQ UG —1-]C✓l� Each manufactured or modular 67.84 '
II dwelling service and/or feeder `
Phone:( 5U g�'7 _ "]� Fax: :( �) 520_Zz�/ tt Reconnect only ( 67.84 �n7�LJ 2
E-mail: 1. 7 t 1 Q((► (04, cry, Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
Business name: Signal circuit(s)or limited-energy See
panel,alteration,or extension. Page 2 2
Address: Each additional inspection over allowable in any of the above
City/State/ZIP: Additional inspection(1 hr min) 66.25/hr
Investigation(1 hr min) 66.25/hr
Phone:( ) I Fax:( ) Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90,00/hr
CCB Lie.: I Electrical Lic.: I Suprv.Lie.: specifically listed(A hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: 167, ■4,
Print name: Date: Plan review(25%of permit fee):
State surcharge(12%of permit fee): g , (_
Authorized signature: TOTAL PERMIT FEE: 15 q
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.
I:1Building\Permits\ELC PermitApp_ELR_ERE.doc Rev 05/21/2013 440-4615T(I1/05/COM/WEB