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Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 111 • 411 EXPIRED Request for Permit Action 9/ ,/'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 0 City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) l Mailing Address: [/ City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID 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). Permit#: L 2 r,2Q /5 —' CO 2$ Site Address or Parcel#: l O SO O `a ( M 61.t.S `r —rre,,, 02 R as Subdivision Name: I /� P632/1 � Lot#: EXPLANATION: Af-S Jc. �€J- PA l )� PSH JE.2 155‘4.-E.b• Signature: Cikl) Ce., Date: o� b�9�/� aZ Print Name: `-?)tio3P,1 g- A-`)6-t—i 1 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 a9 /7 By Route to Records: Date if /7 /7 B Refund Processed: Date `" By Invoice Processed: Date By Permit Canceled: Date ////2// By arcel Tag Added: Date By I:\Building\Forms\RegPermitAction_0 2314.doc Electrical Permit Application EXP n ED holt OFFICE LSE OM.v City o Ti and Received `J f g �+� Date/B : p. © 'i �:s ;11 13125 SW Hall Blvd.,Tigard,OR 97 ?3 `►�r�r N {/ Plan Review Related Permit#: ' p Phone: 503.718.2439 Fax: 503. ')6"` Date/6 : t Inspection Line: 503.639.4175 `Ip1 Ready Date/By: See Page 2 for I I G A R I) Internet: www.tigard-or.gov ��( 4 Notified Method: EMIIIISupplemental Information TYPE OF WORK/ �etIf ,' �14N' PLAN REVIEW 0 New construction Addition/alter 1 1`ire• ., V `►,O Please check all that apply(submit 2 sets of plans w/items checked): 0 Demolition ❑Other: a�,1+� 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. 0 1-and 2-family dwelling 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 0 Other: 0 Fire pump. 0 Installation of 150 KVA or JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived ❑Addition of new motor load of system. Job#: Job site address: L O 500 Si•3 f\YD,EvN1' C" 100HP or more. ❑"A","E","1-2","1-3", City/State/ZIP: '�� -aD ©L'L_ Gl�'2_2.--' , ❑Six or more residential units. occupancy. 0 Health-care facilities. ❑Recreational vehicle parks. Suite/bldg./apt.#: Project name: Az-11,--s-L.\..S L V,l.LL1--CK 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: ,I_( j-, ,ek_ Ca(f3(;0 /ta 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'l 500 sq.ft.or portion 33.92 1 DESCRIPTION OF WORK Limited energy,residential (with above sq.ft.) 75.00 2 P.l.: '6vVNkv.DV i=-a.: -c26- PDA't= 4 w uA,---N- 5.4 SM�/1\ Limitedenergy,multi-family . residential(with above sq.ft.) 75.00 2 0 PROPERTY:OWNER ❑ TENANT Renewable Energy 0 See Page 2 Services or feeders installation,alteration,and/or relocation Name: A / - .P>M � i-Z 200 amps or less 100.70 2 Address: ,p 4 ,, Q ,- AA",,a,�/ (O 201 amps to 400 amps 133.56 2 1— — ire...„......0 -v"'�'l 145 - 401 amps to 600 amps 200.34 2 City/State/ZIP: 1.9../3/ .fin '-D....b 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: 11[e1 l4 ,1 \IAA G4� --D.4 relocation Owner installation:Thisin allation 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, each branch circuit 7'42 2 Contact name: B.Fee for branch circuits without service or feeder fee,first 56.18 2 Address: branch circuit City/State/ZIP: Each add'I branch circuit 7.42 2 Miscellaneous(service or feeder not included) Phone:( ) Fax: :( ) Each manufactured or modular dwelling,service and/or feeder 67.84 2 Email: Reconnect only 67.84 2 CONTRACTOR Pump or irrigation circle 67.84 2 Business name: �.=Z oi_p r--( Sign or outline lighting 67.84 2 . Signal circuit(s)or limited-energy e 2 2 Address: ' (� � v�( ee Pa panel,alteration,or extension. g �d/ Cit /State/ Each additional inspection over allowable in any of the above y �@��/YM1>T� _ 3 Additional inspection(1 hr min) 66.25/hr Phone:( 3 ) J \ ( C2)01 Z 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 Lie.: (S-2 6 0 Electrical Lie.: 0?‘.,`)7 prv.Lie.: /&'ci_ 9— specifically listed('/z hr min) ELECTRICAL PERMIT FEES Suprv.Electrician signature,required: /5-Subtotal: Print name: Date: 0 Plan Review Required(25%of permit fee): State surcharge(12%of permit fee): Authorized signature: liPle,k, 'lib / TOTAL PERMIT FEE: ( d di' 7/ This permit application expires if a permit is not obtained withinin 180 Print name: " VL .� Nr-c'-'c Date: days after it has been accepted as complete. * Number of inspections allowed per permit. 1:ABuilding APermits\ELC_PermitApp_ELR_ERE.doe Rev 06/17/2015 440-4615T(11/05/COM/WEB Electrical Permit Application—City of Tigard Page 2—Supplemental Information Limited Energy Permit Fees: Renewable Energy Permit Fees: ``ggNTIA0100:i*I,Y xIft Fee for all residential systems combined: $75.00 oeReenewanewa° QtyEach ( Total I ble 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 ee d withkva Oa 918-309-0040inaccorance) 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 ❑ 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 ] charged at an hourly(1 hr min) inspections for which no fee is 90.00/hr specifically listed('/z hr min) COMI . IAL WORK ONLY: ELECTRICAL PERMIT SES Fee for each commercial system: $75.00 Subtotal(Enter on Page 1): * 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 t:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015