Permit (39) 1
Electrical Permit Application Ric i...„ FOR OFFICE USE ONLY
Cityof Tigard Received /� �h jfil , Ailpa II
Permit No.: C�
114 Date/B : ice, / /
13125 SW Hall Blvd.,Tigard,OR 97223 MAR 6 ;Plan%Review Other Pen *''.s`
Phone: 503.718.2439 Fax: 503.598.1960 Date/B : `M`:
T I G A R D Inspection Line: 503.639.4175 , r Date Ready/By: auris: ® See Page 2 for
Internet: www.tigard-or.gov Il' Notified/Method: Supplemental Information
TYPE OF WORK 7). lY I .!LY N(O' i'';11.11 41,6'.11).11% PLAN REVIEW
❑New construction ®Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked below):
0 Service or feeder 400 amps or more ❑Building over three stories.
❑ Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
less to ground,or exceeds 14,000 ❑Commercial-use agricultural
❑ 1-and 2-family dwelling ®Commercial/industrial ❑Accessory building amps for all other installations. buildings.
0 Multi-family ❑Master builder 0 Other: 0 Fire pump. ❑Installation of 75 KVA or
❑Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑Addition of new motor load of ❑"A","E","1-2","1-3",
100HP or more. occupancy.
Job no.: Job site address: 13880 SW Pacific Hwy
El Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIP:Tigard OR ❑Health-care facilities. 0 Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name:Tigard Premier Auto Care El Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee• I Total I
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq.ft.or less 168.54 4
Ea.add'l 500 sq.ft.or portion 33.92 1
Tax map/parcel no.: Limited energy,residential
75.00 2
DESCRIPTION OF WORK (with above sq.ft.)
Limited energy,multi-family 75.00 2
reconnect packaged unit residential(with above sq.ft.)
Services or feeders installation,alteration,and/or relocation
200 amps or less 100.70 2
0 PROPERTY OWNER 0 TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
Name:
601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
City/State/ZIP: relocation
Phone:( ) Fax:( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation:This installation is being made on property that I own which is not
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 168.54 2
Branch circuits—new,alteration,or extension,per panel
Owner signature: Date: A.Fee for branch circuits with
0 APPLICANT 0 CONTACT PERSON above service or feeder fee, 7.42 2
each branch circuit
Business name:same as below B.Fee for branch circuits without
service or feeder fee,first I 56.18 2
Contact name: branch circuit
Each add'l branch circuit 7.42 2
Address: Miscellaneous(service or feeder not included)
Each manufactured or modular 67.84 2
City/State/ZIP: dwelling,service and/or feeder
Phone:( ) Fax: :( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E-mail: Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s)or limited-energy
Business name:Willamette HVAC LLC panel,alteration,or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address:3075 SE Century Blvd Suite 206 Additional inspection(1 hr min) 66.25/hr
Investigation(I hr min) 66.25/hr
City/State/ZIP: Hillsboro,OR 97123
Industrial plant(1 hr min) 78.18/hr
Phone:(503)259.3200 Fax:(503)848.2597 Inspections for which no fee is 90.00/hr
specifically listed(Ya hr min)
CCB Lic.: 56951 Electrical Lic.: 34346CRE Suprv.Lic.: 4025LEB ELECTRICAL PERMIT FEES
Subtotal:
Suprv.Electrician signature,required: gey.
Plan review(25%of permit fee):
Print name: mike sicard Date: 3/26/18 State surcharge(12%of permit fee):
TOTAL PERMIT FEE: 4)-In—
Authorized signature: ()%^_cf/ycketThis permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Michael Malstrom Date: 3/26/18 * Number of inspections allowed per permit.
I:\Building\Permits\ELC-PermitApp.doc 07/01/10 440-4615T(11/05/COM/WEB