Permit CITY OF TIGARD ELECTRICAL PERMIT
IN '- COMMUNITY DEVELOPMENT Permit#: ELC2017 00466
D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/20/2017
T t Gait° g Parcel: 2S106DC13400
Jurisdiction: Tigard
Site address: 17034 SW JEAN LOUISE RD
Project: Polygon at West River Terrace,Lot 135 Subdivision:POLYGON AT WEST RIVER TERRACE Lot: 135
Project Description: (1)branch circuit for A/C installation.
Contractor: SIMPLY ELECTRIC Owner: ADLV LAND HOLDINGS LLC
PO BOX 822408 7600 EAST DOUBLETREE RANCH RD, STE
VANCOUVER,WA 98682 SCOTTSDALE,AZ 85258
PHONE: 503-863-8539 PHONE:
FAX: 360-314-4945
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 06/20/2017 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 06/20/2017 $6.74
Type of Use: SF Electrical
Class of Work: NEW
Type of Const:
Occupancy Grp:
Total $62.92
-required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-0010 throug AR 952-001-0 0. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: 4.0 .rte. Permittee Signature: .e Z CL ei"/( LAG/
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale,lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Applica C i
' F01,2 OFFICE ESE Ot.1
II City ofTigard JUN Received t�/�►
'Jg Y123'V2 02��7 RecPlaneivReed
ill/�j em�ittt: '�# -•000 a 13125 SW Hall Blvd.,Tigard,OR 9
Phone: 503.718.2439 Fax: 503.59A11,0,...--
503.5 9$,f r 0F � ARS Date/B ;
t�
4
yInspection Line. 503 639 4175 `-i ' ReadyDate.113y: 7uia G3 e iTI( AR ) UILDiN' DIVISINInternet www.tigard-or.gov BNotified/Method: Supplemental Information
' t' 4r8 % . f5. YY14 fyi, S ; ) t . „'a .-: fI� yUF* a a, ns
®NeW construction 0 AdditiOn/alteration/replacement Please check all that apply(submit/sets of plans ye/items checked):
0 Demolition Other'
0 Service or feeder 400 amps or more 0 Building over three stories.
where the available fault current 0 Marinas and boatyards
s „,f, in° r SLAwo1Ol O C`OI!ST3WJC 1 tOIil :;a` ` .. _: �..:. j exceeds 10,000 snips at 150 volts or 0 Floating buildings.
1-'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 0 Other ❑Fire pump. 0 Installation of 150 KVA or
4
_ x, _ Oi37S ,il f?'tsv or' AW1 *Q AT1Q ;, ,`` a ;r ❑Emergencysystem- larger separately derived.g � i� ❑Addition of new motor load of system.
Job II: Job site address:fl6 ,,S i l-°l l kl�. ,
11 100HP or more.
City/State/ZIP:Tignrd,OR 97224 ❑Six or more residential units. oecppanay.
0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt#;. ®7l Project name:Polygon at West River Ter 0 Hazardous locations. ❑Supply voltage for more than
✓
0 Service or feeder 600 amps or more600 volts nominal
Cross street/directions to job site: .* cr ; S*, E 5.6:* ,?' g_"
Description Qty. i Each i Total i
New residential single-or multi-family dwelling unit.
Subdivision:Polygon at West River Terrrace Lot#: 735 Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#:
Ea.add'!500 sq,ft.or portion. LSO
� 33,92 1
zt?g,: lttsi . DIQh :OWO . r4 . ' ?. is Limited energy,residential '
75,00 2
(with above sq.ft
Limited energy,multi)-family 75:00 2
f residential(with above sq.ft.)
Renewable Energy
0 See Page 2
► 'PRfiP T `OWNE13 i <'I'E! AN T Services or feeders installation,alteration,and/or relocation
Name:ADVL Land Holdings,LLC 200 amps or less 100.70 2
Address:7600 E Doubletree Ranch Road 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Scottsdale,AZ 85258 601 amps to 1,000 amps 301.04 2
Phone:(602)694-4031 Fax:( ) Over 1,000 ampsor 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
,`, ,t �. APPirI fT . :D CQINT i3O i'PERSON Branch circuits—new,alteration,or extension,per panel [
A.Fee for branch circuits yvith
Business name:William Lyon Huules,inc above service or feeder fee; 7.42 2
each brunch circuit
Contact name:Angela Grajewski B.Fee for branch circuits without
service or feeder fee,first
Address:109 East 13th Street branch circuit; 56.18 2
City/State/ZIP:Vancouver,WA 98660 Each add'!branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:(360)695-7700 Fax::(360)693-4442
Each manufactured or modular
dwelling,service and/or feeder 67.84 2
Email:Angela.Grajewski@polygonhomes.com
Reconnect only 67.84 2-
MIa `- x`d C3h¢w r,.r,'l�htsk fl?AG0'QR k fi .�,..�. s . f M _S+'�
�'�� � �rr-� •Amt � _ s _. ��z . • Pump or irrigation circle 67.84. 2
Business name:Simply Electric LLC Sign or outline lighting 67.84 2
Address:PO Boz 82240$ Signal circuit(s)or limited energy ❑ See Page 2 2 1
panel,alteraation,or extension.
Each additional inspection over allowable in any of the above
City/State/ZIP:Vancouver,WA 98682 Additional inspection(1 hr min) 6615/hr ,
Phone:(503)849-8202: Fax:(360)314-4945 Investigation(1 hr min) 90.001hr w''
Email:simplyelectricpdx@gmail.com Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 9 hr
CCB Lic.: 204615 Electrical Lie.: 1067 )Suprv.Lic.:. 4394S speeificallylisted hhrmtn) 000/
Suprv.Electrician signature;required: r S y' ' " 't` it Lr i.0 t#} "1
t i Subtotal: 3_i._._.� .
Print name: Victor Zarzhitsky Date: 2/8/2017 0 Plan Review Required(25%of permit fee):
State;surcharge(12%of permit fee):
TOTAL PERMIT FEE: t
Authorized signature: _ €
This permit application expires if a permit is not obtained within 180
Print name:: Dimitriy Mishchuk Date: 2%8/2017 days after it bas been accepted as complete.
* Number of inspections allowed per permit.
LyBuildingSPermits\ C_PennitApp ELR ERE.doe Rev 06/17/2015 440.4615T(11/05/CQM/LVEB
ii
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
17034 SW JEAN LOUISE RD, SHERWOOD, OR,
97140
Record Type: Record ID:
Residential - Electrical ELC2017-00466
Inspection Type: Inspector:
199 Electrical final Jeff Grove
Result:
PASS - NoCofO
Comments:
Violation Summary:
Inspector Contractor