Permit (52) CITY OF TIGARD ELECTRICAL PERMIT
1111 COMMUNITY DEVELOPMENT Permit#: ELC2019 00384
'TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/10/2019
Parcel: 1 S 134BC00401
Jurisdiction: Tigard
Site address: 12442 SW SCHOLLS FERRY RD 100
Project: Providence Medical Group Subdivision: None Lot: None
Project Description: (2)branch circuits for(2)new RTU's.
Contractor: FOX ELECTRIC COMPANY Owner: PROVIDENCE HEALTH &SERVICES-ORE
9050 SW MONTEREY PL ATTN: REAL ESTATE&CONSTRUCTION
PORTLAND, OR 97225 4400 NE HALSEY BLDG 2 STE 190
PORTLAND, OR 97213
PHONE:
PHONE: 971-563-7215
FAX:
FEES
Quantity Description Date Amount
2 crt Branch Circuits wo/Purchase 06/10/2019 $63.60
Specifics: Service or Feeder
1 ea 12%State Surcharge- 06/10/2019 $7.63
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $71.23
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 u es a••• -• by the Oregon Utility Notification Center. Those rule re set" f•• in OAR
952-001-0010 through OAR 952-001-0090. You, ay obtain a c••y of the rules or dir,ct questions to OUNC by calling 503.2 . •:7.r 1.800.332.2 44.
Issued By: _ _ Permittee Signature:
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 foR of Fit E: t sF:oy 1,1
City of Tigard Received _ EffillIMMINIMM
1,111111 's 13125 SW Hall Blvd.,Tigard,OR 97221 1 v Plan Review -
g Phone: 503.718.2439 Fax: 503.598.1960 `�-�` Et)
Date/B : Related Permit#: -"'(,. )i c-- } '
!AGAR')
Inspection Line: 503.639.4175 Q 919 Ready Date/By: fa See Page 2 for
Internet: www.tigard-or.gov JUN 1 Notified/Method: rte,. Supplemental Information
TYPE OF WORK )- r►GARD PLAN REVIEW
0 New construction Addition/atteration/areplcj►k11StON Please check all that apply(submit 1 sets of plans w/items checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
Ell-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 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: /Z 4"Q se r 4,;i_s IQ,fr� ed 100IlP or more. ❑"A">"E "1-2","1-3",
❑Six or more residential units. occupancy.
City/State/ZIP: �� �� 0/<- 9' `7 2. 2 ❑Health care facilities. 0 Recreational vehicle parks.
❑Hazardous locations. 0 Supply voltage for more than
Suite/bldg./apt.#: Project name: /Z/ZJ; 7fCB-JI{ylft
0--et, 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.
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
�^ / ,p (with above sq.ft.) 75.00 2
"- 'n to a, .LX%S7- ?TV It 2. ITU # S Limited energy,multi-family 75.00 2
Wilk
tlk l� V rA t residential(with above sq.ft.)
Renewable Energy 0 See Page 2
0 PROPERTY OWNER 0 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
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
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
service or feeder fee,first '� 2
Address: branch circuit / 5-�'
City/State/ZIP: Each add'l branch circuit / 7.42 '7 V2
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: i3us,iAP> Sign or outline lighting 67.84 2
Cp s� S W cyst 1-41-1,-.42.4.7 /O l 4 c e�ss GSignal circuit(s)or limited-energy ❑ See Page 2 2
Address: panel,alteration,or extension.
_
eEach additional inspection over allowable in any of the above
City/State/ZIP: i22 i.4 cai& f 0 4. ''7 L Z-5-- Additional inspection(1 hr min) 66.25/hr
Phone:(7`W) 3-6p3 -7 2„, S'"-- Fax:( ) Investigation(1 hr min) 90.00/hr
Email: Industrial plant(1 hr min) 78.18/hr
/e E3 rte/(m 71(/')'*'
1r/ ` NI t L(.Inspections for which no fee is 90.00/hr
CCB Lic.: t /i./ / Electrical Lic.: t -z3 I Suprv.Lic.: 43 _5 specifically listed(%:hr min)
/1 ({+� ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: 1 Subtotal: (6,3 ,too
Print name: Dild __,/,:-.x Tie. Date: 6/6 1 / cj 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee): -74'3
Authorized signature: .,--c2,_____ 4:,,,
TOTAL PERMIT FEE: 71 ..a3
This permit application expires if a permit is not obtained within 180
I. Print 1141116. Dyt,gr(d 4 Dat.: (�`�p !�y day* oma:t h...bean srrapr,a as rnmMom
/ / • Number of inspections allowed per permit.
I:\Buitding\Permits\ELC_PermitApp_ELR ERE.doc Rev 06/17/2015 440-4615T(11/05/COM/WEB