Permit 1"1CITY OF TIGARD ELECTRICAL PERMIT
ICOMMUNITY DEVELOPMENT Permit#: ELC2016-00166
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/03/2016
Parcel: 1S134BC00401
Jurisdiction: Tigard
Site address: 12442 SW SCHOLLS FERRY RD
Project: Providence Medical Group Subdivision: GREENWOOD TERRACE CONDO Lot: 17
Project Description: (2)branch circuits for RTU replacement.
Contractor: FOX ELECTRIC COMPANY Owner: PROVIDENCE HEALTH SYSTEM-OREGO
9050 SW MONTEREY PL ATTN: REAL ESTATE&CONSTRUCTION
PORTLAND, OR 97225 4400 NE HALSEY BLDG 2 STE 190
PORTLAND, OR 97213
PHONE: 971-563-7215 PHONE.
FAX:
FEES
Quantity Description Date Amount
-
2 crt Branch Circuits wo/Purchase 03/03/2016 $63.60
Specifics: Service or Feeder
1 ea 12%State Surcharge- 03/03/2016 $7.63
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $71.23
Required Items and Reports(Conditions)
This permit is subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be don accordance • approved plans. This permit will expire if work is not started within 180 days of issuance, or if •• is suspended for more the 180
days. ATTENTION: Oregon -w -qui s ou to follow the rules adopted by the Oregon Utility Notification Cente Th• e rules are set • h in OAR
952 01-0010 through OAR 952-001-0090.61°
52-6 61-0090.• ay obtain a copy f the rules or direct questions to OUNC by calling 503.232.1•: or 1.86..332.2344.
I ued By: / Permittee Signature: /;;
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale,lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTA •TION ONLY
SIGNATURE OF SUPR.ELEC' Date: (57/5//A,
LICENSE NO. 1,/(54 ?
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Applicat 11 F R 01 I I( F: I SU. O y I.\
ki.$.4.1 1r ����
City of Tigard Received Dates : — QLL7li�r7 Permit#: ('LC ao/!o—Oc/60
;, . 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
■ Phone: 503.718.2439 Fax: 503.598 ?IN
Date/B : Related Permit#:tie . .—bcoa3
Inspection Line: 503.639.4175
P Ready Date/By: kris: ® See Page 2 for
11 G A R D Internet: www.tigard-or.gov + i y, Notified/Method: Supplemental Information
TYPE t.YI 1 VI ]t�i6Atttli PLAN REVIEW
❑New construction dditil)°/.111 � I8CE1T1�nC'" Please check all that apply(submit 1a sets of plans w/items checked):
❑Demolition ❑Other: 0 Service or feeder 400 amps or more 0 Building over three stories.
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ 1-and 2-family dwelling Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
F
❑Multi-family Master builder 0 Other: mall other installations. buildings.
❑Fire re pus mp. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
C ❑Addition of new motor load of system.
Job#: Job site address:
/�2-�41 2 , 'W 'cJ..0 Its ...e-r p IOOHP or more. ❑«A„ ,<E„ «t_2 , <1_3»,
City/State/ZIP: / l9Ch'i� g 7 2 23 ❑Six or more residential units. occupancy.
/ ❑Health raze facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#: Project name: ,�D (' ^,� ❑Hazardous locations. 0 Supply voltage for more than
�� "" v 111.4 w ❑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 1
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 1
DESCRIPTION OF WORK Limited energy,residential 75.00 2
(with above sq.ft.)_exi S refrU 7:f 3 N 14-k
f..1,, Limited energy,multi-family 75.00 2
,144 ci. o u i'. W 1-.1-4k- G-FGA - W le residential(with above sq.ft.)
Renewable Energy 0 See Page 2
0 PROPERTY OWNER 0 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 1
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
0 APPLICANT 0 CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
each branch circuit 7.42 2
Contact name: B.Fee for branch circuits without
service or feeder fee,first hi
Address: branch circuit / 56.18 5 2
City/State/ZIP: Each add'l branch circuit / 7.42 7,q2 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax: :( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: fr-c--9,1e— 6t/St ,� Sign or outline lighting 67.84 2
Address: G�'O S t ) lMort e-� �� Signal aclteration,
or limited-energy
0 See Page 2 2
•ty q C Q� panel, or extension.
City/State/ZIP: ,2 !-Pow d � /{ Cr r�ZZS Each additional inspection over allowable in any of the above
[ ' Additional inspection(1 hr min) 66.25/hr
Phone:(i ) 3 -7215-- Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
c� 7 . L-t)' Inspections for which no fee is 90.001 hr
CCB Lic.:/5 974, Electrical Lic.: G 3 Suprv.Lic.: y3'75 specifically listed(h hr min)
n ELECTRICAL PERMIT FEES
Suprv.Electra tan iirlature,required: &,3, GPO
Subtotal:
Print name: D 0 4 :., Date: 2/21r)/ c... 0 Plan Review Required(25%of permit fee): 'Orf
�/�`� V
State surcharge(12%of permit fee): �. ip3
TOTAL PERMIT FEE: 7 '--2 3
Authorized signature: /
_l This permit application expires if a permit is not obtained within 180
Print name: L%, J•1 ct �/ �X Date: .272, 0/76, days after it has been accepted as complete.
* Number of inspections allowed per permit.
I:1Building\Pennits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(11/05/COM/WEB