Permit (25) CITY OF TIGARD ELECTRICAL PERMIT
} COMMUNITY DEVELOPMENT Permit#: ELC2016-00820
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/24/2016
T f O Parcel: 2S109BA05600
Jurisdiction: Tigard
Site address: 13764 SW MISTLETOE DR
Project: HOLM Subdivision: HILLSHIRE SUMMIT NO.2 Lot: 42
Project Description: (2)branch circuits for swim spa.
Contractor: NORTH BY NORTHWEST Owner: HOLM, CARL W&CAROLYN V FAMILY
326 S 15TH ST. BY NIKKI C HATTON
ST. HELENS, OR 97051 ATTORNEY AT LAW
1211 SW 5TH AVE STE 1900
PORTLAND, OR 97204
PHONE: 503-348-0505 PHONE:
FAX:
FEES
Quantity Description Date Amount
2 crt Branch Circuits wo/Purchase 10/24/2016 $63.60
Specifics: Service or Feeder
1 ea 12%State Surcharge- 10/24/2016 $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 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. 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 o e rules or ect questions to OUNC by calling 503.232.1987 or 1.800.332. 44.
Issued By: �.y�� Permittee Signature: / /' .1116f ✓
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.
Electrical Permit Application _,114---ii'is.'*: FORorrlcL LSI:oNl.\
City of TigardAtt.,,,, i
Received
Date/B : f rte- i ` i)�
11h • 13125 SW Hall Blvd.,Tigard,OR 9 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 C 2d\ Date/B : Related Permit#:
Inspection Line: 503.639.4175 Q Ready Date/By: ® See Page 2 for
116 A R I) Internet: www.tl and-or. ov Notified/Method:
g g y; Supplemental Information
TYPE OF WO " a.►s f 1 �cto1` PLAN REVIEW
New construction Addition/altera,t"�ippp iPlease check all that a
x
❑ a apply(submit 2 sets of plans w/items checked):
y7
a�= ❑Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition ❑Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
XI-and 2-family dwelling 0 Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family 0 Master builder ❑Other: ❑Fireum .
p p 0 Installation of 150 KVA or
JOB SITE INFORMATIONAND LOCATION 0 Emergency system. larger separately derived
❑Addition of new motor load of system.
Job#: Job site address: (3 7‘Lt �_ ,,,,up v.
100HP or more. ❑"A","E","1 2","I-3",
t err ❑Six or more residential units. occupancy.
City/State/ZIP: , ❑Recreational vehicle parks.
0 Health-care facilities.
Suite/bldg./apt.#: Project name: 0 Hazardous locations. 0 Supply voltage for more than
���'!!!!��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 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]500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
75.00 2
�� (with above sq.ft.)
.SZ4), t Sp4• '94 /6.-h2�.,,,7- Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
0 PROPERTY OWNER 0 TENANT , Renewable Energy 0 See Page 2
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
Branch circuits-new,alteration,or extension,per panel
0 APPLICANT ❑ CONTACT PERSON
A.Fee for branch circuits with
Business name: �vvt_e_ ezy L..--i�„ ) above service or feeder fee,
�v each branch circuit 7.42 2
Contact name: B.Fee for branch circuits without
Address: service or feeder fee,first
branch circuit / 56.18 g j y 2
City/State/ZIP: Each add'l branch circuit J 7.42 7.' 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax: :( ) Each manufactured or modular 67.84 2
Email:
dwelling,service and/or feeder
Reconnect only 67.84 2
/// CONTRACTOR Pump or irrigation circle 67.84 2
Business name: /t '',I I5, . /�ivi— Sign or outline lighting 67.84 2
�'v �L/y Signal circuit(s)or limited-energy
Address: Page JS panel,alteration,or extension. 0See Pa e 2 2
City/State/ZIP: 7� Each additional inspection over allowable in any of the above
_ 4/„,/5 ,`
�W 1 1
D--) Additional inspection(1 hr min) 66.25/hr
Phone:(- 5 ) 34., __06-&-..)- Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.://7 /11,0 Electrical Lic.:5-�joC;, Suprv.Lic.:e'j f, 5 specifically listed('/z hr trim)
�JJ��// � 7��ly i / ELECTRICAL PERMIT FEES
Suprv. Electrician sigrllatufe, •required: `/l �l `r Subtotal: -6�
Print name: L t tE Y 5 Date:�C j r2 E"/6
❑Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee): 7. Co:
TOTAL PERMIT FEE
Authorized signature: 7/ _ �.
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 PermilApp ELI'.ERE.doc Rev 06/17/2015 440-46151(11/05/COM/WEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
pie '_nALae NIS .
:;•• . � F..F, " =.n
Description 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
with OAR 918-309-0040) 552.26 2
❑ Heating,Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System* Each additional kva over 25 7.42 3
El 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(1/2 hr min)
E #RICAL.
WORD O -: /PERMTT iI!EES
SubtotalEnteron Page 1):
Fee for each commercial system: $75.00
3' * Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:Building Permits PLC PermiiAppELRERE.doc Rev 06/17/2015