Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I 0
•
Request Permit Action
T I G A R D 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 El Contractor 121 City Staff
(check one)
REFUND OR Name: r
INVOICE TO: (Business or Individual) /� I /�
Mailing Address: / �l
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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#: E/—/2_ go / -D D / 5-9
Site Address or Parcel 9 6-#: O &to /rte/,‘"/C 1 / o y *49e/5--
Project Name: /4414, , j/-k-) Pe-4 7.4-
Subdivision Name: Lot#:
EXPLANATION: AML.,eri A)7— /5 A% 4 I-/C f/05 f?) C1onrre9
Signature: Date: 74(//Si
Print Name: (Jf-66 /4-7)AY/Li 5 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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 '/M6' B (; . . ,, Rte to Bld Admin: Date y AM B
Refund Processed: Date /I By.Ti'j Invoice Processed: Date B
Permit Canceled: Date , /yp y By (17� Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction_062614.doc
Electrical Permit Application �° C FOR OFFICE USE ON 1
illq City of Tigard � ��1._ Received '7 /S� (4,........49 Permit- • 13125 SW Hall Blvd.,Tigard,OR 9 Date/By: y a(v GI�J cj�
Phone: 503.718.2439 Fax: 503.598.1 15 2 G r,lei- . Related Permit#:fit/2 /4t ef1,6ej y!,/
Inspection Line: 503.639.4175 T.eady i/,: , ® See Page 2 for
TI G A R D Internet: www.tigard-or.gov CITY O-1 6AHt ' otifie. -�od: 7 _!iii Supplemental Information
TYPE o I(r PLAN REVIEW
❑New construction Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
❑Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition 0 Other:
where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
❑ 1-and 2-family dwelling Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
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
' ❑Addition of new motor load of system.
Job#: Job site address: 1-q S D �t;,y 1,4(fiF l /-(j`Ti 100HP or more. ❑"A">"E","t-2","t-s",
City/State/ZIP: ��rr- ,, n Z"L ❑Six or more residential units. occupancy.
�.L C-, ❑Recreational vehicle parks.
3 ❑Health-care facilities. P
Suite/bldg./apt.#: VI S Project name: E1 SO FL f}x/i- ❑Hazardous locations. ❑Supply voltage for more than
�, ❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total I
New residential single-or multi-family dwelling unit.
Subdivision: I,ot 4: Includes attached garage.
Tax map/parcel#: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 I
DESCRIPTION OF WORK Limited energy,residential
(with above sq.ft.) 75.00 2
Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
ROPERTY OWNER I ❑ TENANT Renewable Energy ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
Name: ill 6 2 L kN D 4- iL N�e-k_„t j 200 amps or less 100.70 2
Address: 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP: 601 amps to 1,000 amps 301.04 2
Phone:( ) Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 I
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
APPLICANT I ❑ CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: ' fj(._ Atstak a�.C above service or feeder fee,
7.42 2
s-r ri , U 3 Fee branch branch circuit
Contact name: tJ c/v B.Fee for branch circuits without
' 3&Z` � � by branch circuit fee,first 56.18 2
Address: t branch circuit
City/State/ZIP: '7"Z(„ ( I ��3 O 4 Each add'l branch circuit 7.42 2
`�z Miscellaneous(service or feeder not included)
Phone:(SO) ) 7 4 ' O I Fax: :( ) Each manufactured or modular
dwelling,service and/or feeder 67.84 2•
Email: L Al}D� Cd a (��'�rreZ Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Sign or outline lighting 67.84 2
Signal Meta t(s)or limited-energy ( See Page 2 /5-D-‘ ) 2
Address: panel,alteration,or extension. '](ti
City/State/ZIP: Each additional inspection over a lowable in any of the above
Additional inspection(I hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 66.25/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
'CCB Lic.: Electrical Lic.: Suprv.Lic.: specifically listed('/hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: /50.00
Print name: .00.000..„...-______ Date: ❑Plan Review Required(25%of permit fee): ---
State surcharge(12%of permit fee): I g. OU
Authorized signature: TOTAL PERMIT FEE: /ea V,00
This permit application expires if a permit is not obtained within 180
Print name:�7Ev/8V UD fi Atc Date:7�Slid/l� days after it has been accepted as complete.
( * Number of inspections allowed per permit.
1:\Building\Pennits\ELC PetmitApp_ELR_ERE.doex Rev 04/21/2014 440-46151(11/05/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
Description I Qty. I Each I Total I "
Fee for all residential systems combined: $75.00 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 200.34 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301.04 2
50.01 to 100 kva 552.26 2
❑ Garage Door Opener* >100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System* Each additional kva over 25 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 66.25/hr 1
charged at an hourly(1 hr min) .
Inspections for which no fee is 90.00/hr
specifically listed(/2 hr min)
ELECTRICAL PERMIT FEES
COMMERCIAL WORK ONLY:
Fee for each commercial system: $75.00 Subtotal l(Enter t. Page 1):
�' * Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved: .4 0-•: • . .•s • a t; . ■ - • -0,
N • i
/
❑ Boiler Controls
n Clock Systems
❑ Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
❑ Instrumentation
n Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling �-r�
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
1:\Building\Permits\ELC_PermitApp_ELR_ERE.docx Rev 04/21/2014