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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V t i q III _ Request Permit Action .7 4;)//yi I i,,,,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: I I Owner ❑ Applicant ❑ Contractor gi City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) ! v /r4. Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): IN 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#: n-('., o /`7 - 00 33 eo Site Address or Parcel#: / 2t?50 o Life l F i C liw y °n as Project Name: 0)q(Lug,. N F I,»p'5©,,1/4) Coxi3T2u cT/o J Subdivision Name: � Lot#: EXPLANATION: c2 19)€_/.}- 7j LL)Qo (`0 icel--, rT 7- /PE, , &EE f!-290 /Lf-40 /51) t Signature: _ Date: 7///14,e Print Name: 1 E 477 E}M S k, Refund Policy 1. The Community Development 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 b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONLY Rte to S,s Admin: Date --a♦ m :rm2 Rte to Bld• Admin: Date ©a!' : , jaM Refund Processed: Date AM= By J Invoice Processed: Date By Permit Canceled: Date ?MAIM B .l' Parcel Ta:Added: Date B Receipt# Date Method _ Amount$ I:\Building\Forms\RegP ennitAction_062614.doc ill e CITY OF TIGARD ELECTRICAL PERMIT • ' COMMUNITY DEVELOPMENT Permit#: ELC2014-00150 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/02/2014 Parcel: 25111 CA08700 Jurisdiction: Tigard Site address: 9950 SW KABLE ST Project: TODD Subdivision:STATES NO.2 A REPLAT OF"GULF SII Lot: 31 Project Description: (4)branch circuits for kitchen remodel. Contractor: PRO CIRCUIT ELECTRIC LLC Owner: TODD, ROBERT&MARY PO BOX 3948 9950 SW KABLE ST WILSONVILLE,OR 97070 TIGARD, OR 97224 PHONE: 971-563-8211 PHONE: FAX: 503-266-1349 FEES Quantity Description Date Amount 4 crt Branch Circuits wo/Purchase 04/02/2014 $78.44 Specifics: Service or Feeder 1 ea 12%State Surcharge- 04/02/2014 $9.41 Type of Use: SF Electrical Class of Work: ALT Type of Const: Occupancy Grp: Total $87.85 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 is e, if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon tion Ce er. •se rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. Yo � e rules or direct questions to 0 calling 503.232. 87 0 ::00.332.2344. Issued By: _ ' �"�� Permittee Signature: 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 11ll( 1)1I It I I sI O"I 1 Received Cl of Tigard Permit No.: g DataB �� ,// � . r — .I� 1111 • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review I Phone: 503.718.2439 Fax: 503.598.1 ReC C r�y E' Date/By: Other Permit: I 1 c ,�r,1 Inspection Line: 503.639.4175 Date Ready/By: funs: El See Page 2 for Internet: www.tigard-or.gov Notified/Method: /I (f Supplemental Information T9E OF WORK OR 2 2014 PLAN REVIEW El New construction ddition/alteration/re lac Please check all that apply(submit a sets of plans w/items checked below): �D ❑Service or feeder 400 amps or more ❑Building over three stories. ❑Demolition ❑Other: CITY a• where the available fault current ❑Marinas and boatyards. CATEGORY OF CON exceeds 10,000 amps at 150 volts or ❑Floating buildings. less to ground,or exceeds 14,000 ❑Commercial-use agricultural -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","l-2","1-3", Job no.: Job site address: Q�J, 51,41 /�� G 10OHP or more. occupancy. r V "��t ✓� ❑Six or more residential units. ❑Recreational vehicle parks. City/State/ZIP: ❑Health-care facilities. ❑Supply voltage for more than ❑Hazardous locations. 600 volts nominal. Suite/bldg./apt.no.: Project name: cr d ❑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 1 Limited energy,residential DESCRIPTION OF WORK (with above sq.ft.) 75.00 2 q -5 For Nit-no-Pa z_ Limited energy,residential(with muai above sq. 75.00 2 'r��LJ,�E7`(s I`�— residential(with above sq.ft.) Renewable Energy ❑ See Page 2 Services or feeders installation,alteration,and/or relocation ❑ PROPERTY OWNER I ❑ TENANT 200 amps or less I 100.70 2 201 amps to 400 amps 133.56 2 Name: 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:( ) 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, 3 Business name: each branch circuit 7.42 7.q Z 2 B.Fee for branch circuits without Contact name: service or feeder fee,first I 56.18 2 branch circuit Address: Each add'I branch circuit 7.42 _ 2 City/State/ZIP: Miscellaneous(service or feeder not included) Each manufactured or modular 67.84 2 Phone:( ) Fax: :( ) dwelling,service and/or feeder Reconnect only 67.84 2 E-mail: Pump or irrigation circle 67.84 2 ~ CONTRACTOR Sign or outline lighting 67.84 2 ?AO r� __,rte^ L. Signal circuit(s)or limited energy See Business name: C. t panel,alteration,or extension. Page 2 2 Address: P. Z��8 Each additional inspection over allowable in any of the above Additional inspection(1 hr min) 66.25/hr City/State/ZIP: wZ'f. f V / O i 1 7620 Investigation(1 hr min) 66.25/hr Phone:(crib J b3 Z(' Fax:(1,5 Lc", 3Y f Industrial plant(1 hr min) _ 78.18/hr Inspections for which no fee is 90.00/hr CCB Lic.: (� 7,�, �� Electrical ?�.,..G G( �Suprv.Lic.: s�07 5 specifically listed(%1 hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: J 41 f�� Subtotal: Print name: _�'" a y Date: if—Z.—1 r Plan review(25%of permit fee): - 1 State surcharge(12%of permit fee): Authorized signature: TOTAL PERMIT FEE: 0 1.21 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. I:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 05/21/2013 440-4615T(i 1/05/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: RESIDENTIAL WORK ONLY: FEE SCHEDULE Fee for all residential systems combined $75.00 Description I Qty. I Fee I Total I Renewable electrical energy systems: Check Type of Work Involved: 5 kva or less 100.70 2 5.01 to 15 kva 133.56 2 ❑ Audio and Stereo Systems* 15.01 to 25 kva 20034 2 Wind generation systems in excess of 25 kva: ❑ Burglar Alarm 25.01 to 50 kva 301.04 2 ❑ Garage Door Opener* 50.01 to 100 kva 552.26 2 >100 kva(fee in accordance with 552.26 2 n Heating, Ventilation and Air Conditioning oAR918-309-0040) System* Solar generation systems in excess of 25 kva: Each additional kva over25 7.42 3 ❑ Vacuum Systems* >100 kva—no additional charge 0.0 3 ❑ Each additional inspection over allowable in any of the above: Other: Each additional inspection is charged at an hourly(1 hr mi 66.25/hr n) Inspections for which no fee is 90.00/hr specifically listed(1/2 hr min) COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES Fee for each commercial system $75.00 Subtotal: (SEE OAR 918-309-0000) Plan review,if required(25%of permit fee): State surcharge(12%of permit fee): Check Type of Work Involved: TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 ❑ Audio and Stereo Systems days after it has been accepted as complete. • Number of inspections allowed per permit. ❑ Boiler Controls n Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation ❑ HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* n Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations 1:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 05/21/2013 Location: Record Type: Inspection Type: Result: Comments: Inspection Date: Record ID: Inspector: City of Tigard 13125 SW Hal Blvd. Tigard, OR 97223 Tel: 503.718.2439 9950 SW KABLE ST, TIGARD, OR, 97224 Residential - Electrical 199 Electrical ﬁnal PASS - No C of O ELC2014-00150 Jeff Grove Violation Summary: Inspector Contractor