Permit (6) CITY OF TIGARD ELECTRICAL PERMIT
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Permit#: ELC2019-00746
Date Issued: 10/24/2019
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 2S112DC01400
Jurisdiction: Tigard
Site address: 15875 SW 74TH AVE
Project: NW Mothers Milk Bank Subdivision: FANNO CREEK ACRE TRACTS Lot: 4
Project Description: (12)branch circuits for TI.
Contractor: R C COSTELLO ELECTRICAL CONT INC Owner: JDS LLC
PO BOX 336 CRITERION CREEKVIEW LLC
AURORA, OR 97002 BY SPECTRUM REAL ESTATE ADVISORS
1125 SE DIVISION ST#209
PORTLAND, OR 97202
PHONE:
PHONE: 503-982-7400
FAX: 503-982-7400
FEES
Quantity Description Date Amount
12 crt Branch Circuits wo/Purchase 10/24/2019 $137.80
Specifics: Service or Feeder
1 ea 12%State Surcharge- 10/24/2019 $16.54
Type of Use: COM Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $154.34
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 through OAR 952-001-0090. You may obtain a co. . -- . c-or direct questions to OUNC by calling 503.232.1987 1.800.332 2344
Issued By: .y r ermittee 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 OFFICE USE ONLY'
City of Tigard Received
: Permit#: t
sJ DateB / �1 it/� - -_ '
■ 13125 SW Hall Blvd.,Tigard,OR 97223 L Plan Review /
Phone: 503.718.2439 Fax: 503.598.196Q 2 Lp19
I d �} Dan R ,_ _, ..
Inspection Line: 503.639.4175 C -' Ready Date/By: See 'age 2 for
TIGARD Internet: www.tigard-or.gov Notified/Method: 101M Supplemental Information
TYPE OF WORK PLAN REVIEW
❑New construction Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
El Demolition ❑Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
❑ 1-and 2-family dwelling [A/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: 15 8,75 36 j '7 L,+pi fix, looHP or more. ❑"A">"E"> I-2 >"t-3">
❑Six or more residential units. occupancy.
City/State/ZIP: ❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name:Mo+hers AI I K ' /a K 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: FEE SCHEDULE
Description I Qty. I Each I Total
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'I 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
(with above sq.ft.) 75.00 2
S al tic// r1%/-C f/)4-5 -7,G,..- ' Limited energy,multi-family 75.00 2
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
201 amps to 400 amps 133.56 2
Address:
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, .er 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 I 56.18 56,18 2
Address: branch circuit
City/State/ZIP: Each add'1 branch circuit / ' 7.42 81,62.. 2
Miscellaneous(service or feeder not included)
Phone:( ) Fax::( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: a COS f-e d7 E/eC f//C4 / eciedPaC f j ni Sign or outline lighting 67.84 2
Signal circuits)or limited-energy 0 See Page 2 2
Address: Pv 3x 336 panel,alteration,or extension.
City/State/ZIP: q Each additional inspection over allowable in any of the above
tY 4,np,Gi O ,� '7®0 L- Additional inspection(1 hr min) 66.25/br
Phone:(50 j) 0 y_6i Scs, Fax:( ) Investigation(1 hr min) 90.00/hr
Industrial plant(1 hr min) 78.18/hr
Email:
rctos-te (laPtoc a0I W/H Inspections for which no fee is
90.00/hr
CCB Lic.:0,7 L10 Z Electrical Lic.: 3-3 tem_ Suprv.Lic.: 3134/S
specifically listed(''/z hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required:'.. e".2 ,_„'' Subtotal: )31 r
Printname:•1.701/45.e,,. e 00S4i1 Date: !v'Zti/iS0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee): /(a.$11
Authorized signature: TOTAL PERMIT FEE: I S L,.3L3,
This permit application expires if a permit is not obtained within 180`
Print name: Date: 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