Permit CITY OF TIGARD ELECTRICAL PERMIT
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• I COMMUNITY DEVELOPMENT Permit#: ELC2015-00949
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/09/2015
Parcel: 2S112AC01800
Jurisdiction:
Site address: 15055 SW 72ND AVE
Project: Pacific Pride Subdivision: FANNO CREEK ACRE TRACTS Lot: PTS 45
Project Description: Removing and replacing existing equipment on gas islands to replace underground pipe.
Contractor: COUNTRYSIDE ELECTRIC INC Owner: PETROCARD SYSTEMS INC
PO BOX 397 730 CENTRAL AVE S
JEFFERSON, OR 4884S KENT,WA 98032
PHONE: 541-974-6415 PHONE:
FAX:
FEES
Quantity Description Date Amount
6 crt Branch Circuits wo/Purchase 12/09/2015 $93.28
Specifics: Service or Feeder
1 ea Plan Review Electricial 12/09/2015 $23.32
Type of Use: COM 1 ea 12%State Surcharge- 12/09/2015 $11.19
Class of Work: ALT Electrical
Type of Const:
Occupancy Grp:
Total $127.79
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. ATTE - . - ••n law re•uires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001 s'10 through OAR 9 :00 -0090 Y. may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Iss •d 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: /
/�p /
LICENSE NO. '7 O 7/5
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kopt 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 FOR OFFICE USE ONLY
Received _
CityofTigardPermit 5: Lig
5 g ct`v Date/By:/A / I r 1 1Latx 5 ��q'l 7
71 13125 SW Hall Blvd.,Tigard,OR 9722 R Plan Review
Phone: 503.718.2439 Fax: 503.598.19 Date/By: 7/�f 103 Q1 Related Permit S:
Inspection Line: 503.639.4175 Ready Date/By. f Juris: ® See Page 2 for
I 1 t,1 I:1 t Internet: www.tigard-or.gov nF r' 1 2015 Notified/Method: as • 5-r r - - - Supplemental Information
3:y..PE OF WORK i ��//(�1��y� lid` x�'` �4tlys �/(rl/ • PLAN REVIEW
❑New construction Addition/alteration( lIMEnt IVtY � p IIII s' eek an that apply(submit 2 sets of plans" items checked):
❑ 0 A1(r Dtv���j 0 Service or feeder 400 amps or more 0 Building over three stories.
DemolitionOther: BUILD a where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
0 1-and 2-family dwelling E omtnercialiindustrial 0 Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family 0 Master builder 0 Other: ❑Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
SU) J��A J� 0 100Addition of new motor load of system.
Job#: Job site address: µ
OOHP or more. ❑"A" "E" "1-2" "I-3"
City/State/ZIP: 1-1-, aco\ a oilaz-1 !psi or more residential units. occupancy.
r !y��^ ealth-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name c,;( I C 1[ i�� Hazardous locations. 0
600 Supply
voltage for more than
❑Service or feeder 600 amps or more.
Cross street/directions to job site: FEE SCHEDULE
Description I Qtv. I Each I Totat I •
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'l 500 sq.ft.or portion 33.92 I
DESCRIPTION OF WORK Limited energy,residential 75.00 2
.11pp �/��r 1 ! `,_ (with above sq.ft.)
�f-vokie eA Iaee +htr 6.y `�.. 1 ( tALK � Limited energy,multi-family
1 75.00 2
t�q, , � as& 1g S le)
e) Ct residential(with above sq.ft.)
� T U �'�` N pH'P Renewable Energy 0 See Page 2
0 PROPERTY OWNER ❑"TENANT Services or feeders installation,alteration,and/or relocation
Name: 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
❑ APPLICANT ❑ CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
-a\ A.Fee for branch circuits with
Business name: j above service or feeder fee, 7 4�
(j' '_f y each branch circuit
Contact name: �\ 0, `-. I) B.Fee for branch circuits without
• service or feeder fee,first 2
,` V" �` tlt 56.18 �� l�-
Address: ` 1N[-Jf' ��'i1' branch circuit •
C/' \ s Each add'I branch circuit 5 7.42 33 1D 2
City/State/ZIP: vvv �
Phone:( ) Fax: :( ) I P _ Miscellaneous(service or feeder not included)
V"
r �� Q • •t, Each manufactured or modular o
�/` /J Q1 dwelling,service and/or feeder 67.84 _
Email:
Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: �itA lv4e Icel j-Cr Sign or outline lighting 67.84 2
S91 Signal circuit(s)or limited-energy 2
Address: panel,alteration,or extension. 0 See Page 2
G G r X) j c ' ��r ^ Each additional inspection over allowable in any of the above
City/State/ZIP: '"�( Additional inspection(1 hr min) 66.25/hr
Phone:sti I )C�"'l d (,L g 5 Fax:( ) - Investigation(1 hr min) 90.00/hr
Email: 4vuA�e.it Ci Cy.61ce" eJ1 �rc,Go Industrial plant(I hr min) 78.18/hr
�—" Inspections for which no fee is 90.00/hr
/./•�
CCB Lie.: Electrics •: specifically listed Ci hr min)
t�L.�`' I C� tV 4t Suprv. Lica:
1 / so,.! . ELECTRICAL PERMIT FEES
Suprv.Elect 'clan. i aequired: t '�`'=;� MORA'
� Subtotal:
Print name: It lip �Q�f.A-le+ I Date: 0- 1 0 Plan Review Required(25%of pennit f'ee): 7-N.1
State surcharge(12%of permit fee): it a1
Authorized signature: TOTAL PERMIT FEE: 121_7 9
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 06;17,2015 440-4615T(11,05COM%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 1 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
n Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
n 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
with OAR 918-309-0040) 552.26 2
n Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System*
Each additional kva over 25 7.42 3
n Vacuum Systems* >100 kva-no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
n Other: Each additional inspection is 66.25/hr 1
charged at an hourly(I hr min)
Inspections for which no fee is 90.00/hr
specifically listed('h hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system: $75.00 Subtotal(Enter on Page I):
* Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
❑ Clock Systems
TI Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
❑ Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
Outdoor Landscape Lighting*
n Protective Signaling
n Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:\Building\Permits\ELC_I'et mitApp_ELR_ERE.doc Rex'06/17/2015
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
15055 SW 72ND AVE, TIGARD, OR, 97224
Record Type: Record ID:
Commercial - Electrical ELC2015-00949
Inspection Type: Inspector:
199 Electrical final Jeff Grove
Result:
PASS - NoCofO
Comments:
Violation Summary:
Inspector Contractor