Permit Support Document (165) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ra ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE T CTION FOR THE ITEM(S) CHECKED (1):
CANC ;L ID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
P )
Permit#: J j(La[) OC)`&3
Site Address or Parcel#: //3020 ,500 Z 'o Awl-- Sy
Project Name:
Subdivision Name: Lot#: _
EXPLANATION: CA/717-4G-6!1 £,2c. 14 3:.1v
A ' ba
!C<c.14 VPr:7 afr l,/ �,•, an/el 4 .,Are-41 iet/i74).!/
Signature: Date: A1/451/41
Print Name: ,V�� 7 i5x,4�
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date /071)>V/1-., By /1.). Route to Records: Date 2v 2 / •
B
Refund Processed: Date By�.(i Invoice Processed: Date By
Permit Canceled: Date/ / j/ . By -;(#' - Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_092314.d6c
Electrical Permit Application FOR FOR OFFICE USE ONLY
City of Tigard�.J y Date/B y a/t) t, ;- Perm": Ei!4�1& --Calle
.11111 II 13125 SW Hall Blvd.,Tigard,OR 9722 AE Plan Review K
Phone: 503.718.2439 Fax: 503.598.1 0Date/By: Related Permit#:
T I G A R ll Inspection Line: 503 639 4175 � � + q 016 Ready Da 7 s ....... ® See Page 2 for
Internet www.tigard-or.gov 1 H Notif+ed/M d: 0 1 i .., Supplemental Information
[100 '7r` :!Yq:;, ,``5�-.' Y p *+ 7;`- e :- eye; +.�. t
4 s , '#�r-� .;'" f .t.; ._ i 44 ;& ia3 ad's:.., .s:. , d3 ,;v:'-k,.!.' ,,•.I -;•,C..+ 'i ,ka;„ -Ahi.!e,_
®New construction ❑Addition/alteratio ,. a err� DIVISIO SIO Please chec all that apply(submit 2 sets of plans w/items checked):
�tl �"171 l 0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition ❑Other:
�� where the available fault current 0 Marinas and boatyards.
� j
r, r t g a 1 g (t j exceeds 10,000 amps at 150 volts or 0 Floating buildings.
El1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family ❑Master builder ®Other: 0 Fire pump. 0 Installation of 150 KVA or
z1; 5 g ; 3 g ,#t e;: "j p+' (s j 4 i. m ❑Emergency system. larger separately derived
_ ;; _ k ❑Addition of new motor load of system
Job#:8846 Job site address:11320 SW Walnut St 100HP or more. ❑"A","E","t-z "1-3",
City/State/ZIP:Tigard,OR 97223 0 Six or more residential units. occupancy.
❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name: 0 Hazardous locations. 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: rt , r'ry I tm §
Description 1 Qty. 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#:
r_ Ea.add'1500 sq.ft.or portion 33.92 1
rog �. _ . �r � , .. , r;,. § ,5. . 4�1 mit,,.. ; ; ii,4``s ; . Limited energy,residential
Overhead to underground house conversion (with above sq.ft.) 75.00 2
Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
Renewable Energy 0 See Page 2
a oa w s1 * - t.f sR ,„,„,.„„:4,,,,v,,* x,-
4 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
� �'{� 14"_f` ,, ,,et Branch circuits—new,alteration,or extension,per panel
1Ys:y,na,. `�w:m. .,�+" ,,'t" , �,i ,�' n -', .'18-i .1 r ....♦ �
'''''''''44'-''-`1"1' 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
Address: service or feeder fee,first 56.18 2
branch circuit
City/State/ZIP: Each add'l branch circuit 7.42 2
Phone: Miscellaneous(service or feeder not included)
( ) Fax::( ) Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Email:
Reconnect only 1 67.84 67.84 2
,zoa �_�,,.� wg. aza4qi 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, panel,alteration,SUITE A Signal Meru tion,or extension.t(s)or limited-energy 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
Industrial plant(1 hr min) 78.18/hr
Email: marilyn.achterman@northstarelect.com
7,616 Inspections for which no fee is 90.00/hr
CCB Lie.: 90454 Electrical Lic.: 34-359/G2C /r' Suprv.Lic.:i58535 specifically listed('/hrmm)
' EL CTRICAL PERM1T' S
Suprv.Electrician signature,required:
Subtotal:
Print name: Jesse N.Culp ate: 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