Permit CITY OF TIGARD ELECTRICAL PERMIT
:'' COMMUNITY DEVELOPMENT Permit#: ELC2016-00955
T1GARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/20/2016
Parcel: 2S103AA00301
Jurisdiction: Tigard
Site address: 11015 SW WALNUT ST
Project: HINTZ Subdivision: None Lot: None
Project Description: Reconnect only.
Contractor: NORTHSTAR ELECTRICAL CONTRACTORS Owner: HINTZ, SHIRLEY ANN
19450 SW CIPOLE RD, STE 107 11015 SW WALNUT ST
TUALATIN, OR 97062 TIGARD, OR 97223
PHONE: 503-612-0840 PHONE:
FAX: 503-612-0891
FEES
Quantity Description Date Amount
1 ea Reconnect Only 12/20/2016 $67.84
Specifics:
1 ea 12%State Surcharge- 12/20/2016 $8.14
Electrical
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $75.98
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. Yo, tai a rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: A — Permittee Signature: 55 �r,�t
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 tiVi FOR OFFICE USE ONLY
City of Tigard 'Wt +'" Received
- —mit#:
AN
at Date/By: 4 2�TJ iL ,, ,a--14 i -- ,
ill
13125 SW Hall Blvd.,Tigard,OR 9722 `i�
p ry Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 D L
0 Plan
: Related Permit#:
T I GARD Inspection Line: 503.639.4175 Ready Date/By: H See Page 2 for
Internet: www.tigard-or.gov / C �(1 'A1e��Notified/Method: IiiM Supplemental Information
TYPE OF WORT ,�y ' rA IN yIalt 4 PLAN REVIEW
®New construction ❑Addition/alteratio_ • nt iks Al Please check all that apply(submit 2 sets of plans w/items checked):
0 Demolition ❑Service or feeder 400 amps or more 0 Building over three stories.
❑Other' 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 0 Commercial/industrial 0 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: o Fireum .
p p 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
0 Addition of new motor load of system.
Job#:8846 Job site address: 11015 SW Walnut St 100HP or more. ❑"A","E","1-2","t-3",
City/State/ZIP:Tigard,OR 97223 0 Six or more residential units. occupancy.
0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name: 0 Hazardous locations. 0 Supply voltage for more than
0 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.
Tax map/parcel#: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
Overhead to underground house conversion (with above sq.ft.) 75.00 2
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
0 PROPERTY OWNER Renewable Energy 0 See Page 2
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
,ty/State/ZIP:
ne:( ) Fax:( ) 601 amps to 1,000 amps 301.04 2
Over 1,000 amps or volts 552.26 2
Email: Temporary services or feeders installation,alteration,and/or
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 ❑ CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
7.42 2
each branch circuit
Contact name: B.Fee for branch circuits without
Address: service or feeder fee,first 56.18 2
branch circuit
City/State/ZIP: Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax::( ) Each manufactured or modular
Email:
dwelling,service and/or feeder 67.84 2
Reconnect only 1 67.84 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name:NORTHSTAR ELECTRICAL CONTRACTORS Sign or outline lighting 67.84 2
rcu
Address:9130 SW PIONEER COURT,SUITE A Signal alteration,or extension.t(s)or limited-energy
panel, 0 See Page 2 2
City/State/ZIP:WILSONVILLE,OR 97223 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:(503)612-0840 Fax:(503)612-0891 Investigation(1 hr min) 90.00/hr
Email:marilyn.achterman@northstarelect.com Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is
CCB Lic.: 90454 Electrical Lic.: 34-359C Su rv.Lic.: 58535 specifically listed(1/2 hr min) 90.00/hr
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: ,,_l
'�v Subtotal:
iot name: Jesse N.Culp Date: 12-7-16 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee): 8.15
Authorized signature: TOTAL PERMIT FEE: 75.99
This permit application expires if a permit is not obtained within 180
Print name: Date: 12-7-16 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(11/05/COM/WEB