Permit Support Document y q CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT P1,47;920....„ Permit#: ELC2014-00225
T[G A R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 v<.. Date Issued: 05/07/2014
Parcel: 1 S 134 DB00700
Jurisdiction: Tigard
Site address: 11175 SW 114TH PL
Project: 231614 Violette Subdivision: WINTERS ADDITION Lot: 1,PLUS
Project Description: Bath(2)remodel. 6/17/14,reprinted to add(1)subpanel.
Contractor: BOONES FERRY ELECTRIC INC Owner: VIOLETTE, LORITTA COLLEEN&
PO BOX 628 LOUIS E
WILSONVILLE, OR 97070 11175 SW 114TH PL
TIGARD,OR 97223
PHONE: 503-682-4936 PHONE:
FAX: 503-682-7946
FEES
Quantity Description Date Amount
1 ea Services or Feeders-200 06/17/2014 $100.70
Specifics: amps or less
2 crt Branch Circuits w/Purchase 06/17/2014 $14.84
Type of Use: SF Service or Feeder
Class of Work: ALT 1 ea 12%State Surcharge- 06/17/2014 $13.86
Electrical
Type of Const:
Occupancy Grp:
Total $129.40
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 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. ENTION: Oreg law r=quires you to follow the rules adopted by the Oregon Utility -- •• -nter. Those rules are set forth in OAR
952- 1-0010th •ugh OAR 95 -r• -01•0. •u may obtain a copy of the rules or direct questions to 9t1NC by calling • . 987 or 1.800.332.2344. 1
S
Is ued By: 'I / /i ! � Permittee Si. . �Yi '
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.
Jun, 17. 2014 2 it pp DECEIVE No. ONI P. 1
L+'Iti•Ct1�1Ca1 �'@1'll]lIf.cA. ljCatxp FOR >_Sr 0'�i 1
City of Tigard
71 Pe''''t 11°.E LC-2 d 19--Q O 1-Z-5-13126 swxall Blvd.,Tigard,oR 922
.0 Phone: 503.639 4171 Fa 503.59891j 7 2014 x
Pilo arsoew —
p,kgy Other Permit
_`,r_ Inspection Line: 503.639.4175 naps RIodyBlr. hat See Page 2 for
T So Y OF T.1G ! T1eti4rdMSetbod Supplemental Information
intemec www t2 don. v � �
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4. �; tiff's.. .•F t zt.5.�`�.ri,r-.,..: 1-,;:, :'.4.:,',1,;;;;.z a.L"4
❑New construction Addition/alteration/replacement �Plesae cbeek all rkat apply(submit 2 sets of plans /tom da�lzd below):
❑Service or feeder 400 amps or mote ❑Building over three stoic,.
❑Demolition ❑Other: where the ava0ablc fault current ❑Marinas aodboatyards.
'';`;;=+, "4•:• .7�"' 'r= ` 7.47:•-,"'°x"'•y''`i;b'`:r'w.;?.S•'r�''";7 exceeds 10.000 amps at 150 volt or ❑Floating bufdingw.
•,. „:$,:::':.:j:,,;,,..'":',, i •. . c 4,s?s.a .:n':,:�-`"�'"r;?r, err, , ;c.�;•,. a - - hNs to ground,or exceeds 14,000 ❑Cotnmereial-use agricultural
IQ 1-and 2-family dwelling 0 Commercial/industrial ❑Accessory building amps for all other it nations. build.
❑M u l t i-f a m i l y . ❑Mastcr builder ❑.Other ❑Fire pimp. D 1, ra of 75 s VA or
lrmerBency system larger separately derived.system.
't,t N t a, • •- ,-__ (0 Addition of new motor load of ❑-A-•"E-,-1-2-,-1-3-,
Job no.:/.3 / ,/y Job site address: 1 j 117 S 5 w 114, Th pi
10011?ix or or more.si �x
❑Six or more residential units. ❑Recreational vehicle pocks,
y . .�i�kls-cane l8catitiet: �P Y more:
r: WI 1.s a n 1�.i f l f _ 600 volt oomina.
_ (1 0 Flaardou loc+tio�.
S u i t e/b l d g f a p t no.; I P r o j e c t mole: V(o 1 e-'I T e D Service or fir 6^00 amps or more J �-
,; c'`°v Aa7r 7, ^r.
Cross street/directions to job site: -tanning. (icy, ft, i Teel •
. - • New-residential single-or multifamily dwelling unit
' Includes attached garage.
Subdivision: € Lot no.:
1,000 s9•h•or less MI 168.54 4
-- Ea add'l 500 sq.ft or portion 11111 3392 —Q
Tax map/parcel na Limited energy,residential
,---- 4 67.84 2
rra n - A•" with above sq.ft,)
,..;•:.:1:: _;. „."..y.- _.s n Aw.43.7:au:N..Lz., . . G«, '
Cnergy,multi-family
la d sv vy.>�/ - 5
r
residential(with above a._11.1 R1 67.84 2
Services or feeders installation.alteratioa,and/or relocation
200 amps or lees ) 100.70 2
x-,-;..,.,. ` 14 A�•�•*,•�•�^•�W•ISH' '='d ; ..:ci_7;ei7',�,-�” c. ` ottg. •.K igi- 7:;. 201 10 400=Ps — 133.56 MI
-a,.r• lot F'+ ?;l ' d�aw,v; �' a-..,'... f.•r: .ii:,i.8.i�.i' ;"a.,,,,.:'f---4,n. ar°ps
_—..,.,..a, +%.,. ..rT=::•,'f°.a/.f. ':T'9:4M�'. .,,;r.;-,3^,e '.-,F'`:^ pit" '7.eaJ" .s+iv�ae` '�„w�'Y,•••:«]::�.
. ,.., 401 amps to boo amps 200.34
Name: — - 601 amps to 1,000 amps I 301.04 2
dt 55: Over 1,000 amps or volts .551261 1_2
' Temporary services or feeders installation,alteration,andlor 1
City/State/ZIP: relocation _-
Phone:( ) Fax:( ) 200 amps or less 5936 1 ;
201 amps to 4A0 amps 125.08 2
owner instillation:This installation is being made on property that I own which is not 401 amps ro 599 amps 16g.54 2
intended for sale,lease rent,or exchange,according to ORS 447,449,670,and 701. taromc6 m_ alterations or exttasaoa.per panel
Owner signature: Date: A Fee for branch circuits with
: %� 5 a . .7?� , a ti above service or feeder fee,
7.42 2 p: �a� � ° °"- a ° ' e, , eti. -._ ,:.,e i 7.:r_. '- .
_.._. each branch circuit
Business name B.Fee for branch circuits widwrc
_ service or feeder fee,first 56.18 2
branch circuit
Contact natrle: Each arid•I branch circuit 7.42 2
4 —
Address: Miscrilaneods(service or feeder not included) _ -
- -- Each Inantfcoued or modular 67.84 2
City/State/ZIP: dt►'eU.in&service andlor feeder
Fes' Recel a er o10Y 67,84 2
Phony.( ) 67.84 2 irrigation-E-mail.
Sign o lighting • 67
.777
f outline 67.94
--- al .•ew...�;er,T•.1,4,7., r••�G^,•'�y Y-.-r: ''
' <, a ?: .`� Tr ic. -_ y.... Signs]circuit(s) limited-energy 1
_ .__ _ pan�alterati Or top. i'�$a . .., ._._..._....�- .. .
Business name:Boone Ferry Electric . -Each_additional.Inspection over allowable to s of the above
Address!P.O.Box 628
Additional inspetctou(1 hr min) 6625/hr •
Investigation(1 hr mint) 6675/hr
City/State/ZIP-Wilsonville OR 97070 Indust ial plant(1 hr min) 78.18/br
Phone:(503)6824936 Fax:(503)681x7946 Inspections for which no fee is 9000/re -
__ _ _ - listed i4 hr mm I
CCB Lie.: 88482 Electrical Lic.: 3-223C Suprv.Lk.: —
- - • Subtotal. 40 0 _7-0 r I'
Ruprv.Electrician signature,required: Plan review(25%of permit fee): 3
State surcharge(12%of permit fee): k t O% • °}
r'rint name: Date:
- 'L TOTAL PERMIT FEE 0
Authorized si This permit appbcspon expires If a permit is not optaiaedwirisin l8tJ J
days after It has beau accepted as rnmpleta t
Print name: /c ,t"•*1 r e S 47 4 Date:6' /7 / • Number of inspections allowed per permit `()6
I:1Buildina wmtti'E-C•PetareMD.doc 10/01 �46 I�1U0 yyIM �/�Ya�
Jun, 17. 2014 1 : 52PM No, 2466 P. 2
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
:II Payment Authorization Form
13125 SW Hall Blvd. • Tigard, Oregon 97223
T I G.ARD Building Division: 503.718.2439 • Planning/Engineering: 503.718.2421
Fax: 503.598.1960 • Internet: www.tigard-or.gov
Permit No.: EL( 20 I 't - 60 225
Job Site Address: 1 )1 7 s St•✓ /) ' 1k P L
Project Name: (j) 0 )IL4 4 T
Credit Card Information: Please print clearly.
All information below is requited to process Card Not Present Transactions.
VISA ❑ MasterCard 6 0-3 yo(0 / 6 9 6 7 0 4 8
In I Discover (credit card account number on front of the card)
Expiration date: e// 6
Card Validation Code: This eeavrity n fiber is located on back of the card in the
3ignatare panel after the last 4-digits of the card number.
Cardholder name on card: Boones Ferry Electric
Contact phone number: (503 )682-4936
Billing address for this card: PO Box 628 Wilsonville OR
Billing ZIP code: 97070
Trust Account Information: For permit fees to be paid from established trust account.
Trust account number: N / A
Contractor/Business name: N / A
Contact phone number: N / A
I hereby give the City of Tigard permission to pay for the above referenced
permit with the credit card or trust account provided above.
Authorized Signature:
Name Printed: /--e-A' )) PI e S t 1 v,e"
Date: 0 7/J
Please FAX this completed and signed form to 501598.1960.
*** DO NOT EMAIL THIS FORM. ***
For your protection, this form will be destroyed after your payment has been processed.
I.\Builduto\Forms\PeymcntAuthonzatton.J)8O113.doe