Permit CITY OF TIGARD ELECTRICAL PERMIT
II I ' COMMUNITY DEVELOPMENT Permit#: ELC2015-00613
T IGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/04/2015
Parcel: 1 S 136C 603800
Jurisdiction: Tigard
Site address: 11055 SW 83RD AVE
Project: BRADLEY Subdivision: STEVE&HUGHIE'S PLACE Lot: 10
Project Description: Panel replacement.
Contractor: JOHN VERTNER ELECTRIC Owner: BRADLEY, PAULINE L
PO BOX 473 11055 SW 83RD AVE
OTIS, OR 97368 TIGARD,OR 97223
PHONE: 503-989-0409 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Services or Feeders-200 08/04/2015 $100.70
Specifics: amps or less
1 ea 12%State Surcharge- 08/04/2015 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
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 160
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 ma obtain= r[c.,;.. rules or direct questions to OUNC by calling 50 .1 87 or 0.33 .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.
- Wig'.._. ,).- ' 7/e- ,)-Y3 / 315_ 5w
�� ( 1 gii
ec rical Permit Application Project# /
'- // B/Vd
1.� Washington County, 155 N. Ist AV,Suite 350,MS 12,Hillsboro,OR 97124,
,,k. o_ Phone: 503-846-3470, Fax: 503-846-3993/Iutbldg @co.washington.or.us Permit# 44,20is---- de fo 13
Inspection Requests: 503-846-3699/www.co.washington.or.us/piro-71.9, �
ey
TYPE OF WORK PLAN REVIEW
❑New construction ition/alteration/replacement ❑Other Please check all that apply:
❑ Service or feeder 400 amps❑ Hazardous locations
or more where the available❑ Service or feeder 600 amps or more
CATEGORY OF CONSTRUCTION fault current exceeds
❑ Building over three stories
1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building 10.000 amps at 150 volts or Marinas and boatyards
less to ground,or exceeds
❑Multi-family ❑ Master builder ❑Other: 14,000 amps for all other CI Floating buildings
JOB SITE INFORMATION AND LOCATION installations. ❑ Commercial-use agricultural
buildings
��V( ❑ Fire pump
Job no.: Job address: 105 S jV 531'-') AVE"- ❑ Emergency system ❑ Installation of 150 KVA or larger
separately derived system
City/State/ZIP: 'f_(,Pr Q ) () 9G) C17 3-8 4)� ❑ Addition of new motor ❑ A, «E,""I-2,""1-3"occupancy
) load of I OOHP or more
Suite/bldg./apt. no.: Project name: ❑ Six or more residential Units Recreational vehicle parks
CI Health care facilities ❑ Supply voltage for more than
Cross street/directions to job site:
600 volts nominal
FEE SCHEDULE
Description I Qty. Fee Total *
Subdivision: Lot no.: 10 I Residential single-or multi-family dwelling unit.
Includes attached garage.
Tax map/parcel no.: 1,000 sq.ft.or less 167.00 4
DESCRIPTION OF WORK Ea.add'I 500 sq.ft.or portion 47.00
Limited energy,residential
lCi �,Ia (with above sq.ft.) 107.00 2
Limited energy,multi-family
107_00 2
residential(with above sq.ft.)
PROPERTY OWNER I ❑ TENANT Services or feeders installation,alteration,and/or relocation
Name: "Po�l,�-l(}--1 t BM-6 I't(i 200 amps or less / 10700 I/7ij,'7p 2
201 amps to 400 amps 161.00 2
Address: t ID5.5 5 W g3(2..) Au E 401 amps to 600 amps 214.00 2
-f^- � (� OO ( n 7 �,f I 601 amps to 1,000 amps 321.00 2
City/State/ZIP: 1 J-t� l / 1 3 - `{ Over 1,000 amps or volts 642.00 2
Phone:( ) Fax:( ) Temporary services or feeders installation,alteration,and/or
relocation
Owner installation:This installation is being made on residential or farm property owned by me or a member of 200 amps or less 107.00 2
my immediate family. This property is not intended for sale,exchange or rent.(ORS 479.540(I)and 479560(1).
201 amps to 400 amps 161.00 2
Owner signature: Date: 401 amps to 599 amps 214.00 2
❑ APPLICANT 0 CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
�hn ` , {LEC (C A.Fee for branch or feeder fee,
Business name john above service or feeder fee, 9.50
OI r J UEms\ branch 2
Contact name: �r(�--! B.Fee for branch circuits
Address: �Vy q• ' without service or feeder 107.00
1 ,�LL I fee,first branch circuit 2
City/State/ZIP: C-) On Cf�
Each add't branch circuit 9.50
Miscellaneous(service or feeder not included)
Phone: (563) g 9--6 Fax:( ) Each manufactured or modular` dwelling,service,and/or feeder 113.50 2
_E-mail: �('� l �el'ec �Q (�F�1�( 1,CG`"j
J- C71 Reconnect only 107.00 1
CONTRA OR I Pump or irrigation circle 107.00 2
Business name` 04/\.{ V ERIN Sign or outline lighting 10200 2
pc u y , r 5 ' Signal panei,al er t on,or
Address: 4 energy panel,alteration,or
107.00 y extension.Describe:
City/State/ZIP: ORE- C,Jl 9 t-y 5p
2
J
Phone: (5D3)9e61,-a 9 Fax:( ) , Each additional inspection over allowable in any of the above
Per inspection 107 00
E maillGha v e(eefri C63Tti j.t'C• ?�CCB lie,no.: , �o I g
`� _' Investigation fee(see compliance)
Electrical lic. no.:c (( 7 7/i/)7 City or metro lie.: Other:
ELECTRICAL PERMIT FEES
Supervising r ^ �7/J /1 7„°signatre,r equired: Subtotal a
7v
Print name:Jahn `e Y to e Date: Plan review(25%of permit fee)State surcharge(12%of permit fee) l2 a Authorized -
signature: TOTAL PERMIT FEE //r) -76
This permit application expires if a permit is not obtained
Print name: Date: within 180 days after it has been accepted as complete
*Number of inspections allowed per permit Revision 6/13