Permit (2) CITY OF TIGARD ELECTRICAL PERMIT
a. COMMUNITY DEVELOPMENT Permit#: ELC2020-00017
Date Issued: 01/24/2020
TLS ^,A RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S112DA01400
Jurisdiction: Tigard
Site address: 6650 SW REDWOOD LN 190
Project: Integrity Medical Subdivision: 1996-048 PARTITION PLAT Lot: 2
Project Description: Electrical for TI.
Contractor: JOHANSEN ELECTRIC INC Owner: PACIFIC REALTY ASSOCIATES
16869 SW 65TH AVE, SUITE 311 ATTN: N PIVEN
LAKE OSWEGO, OR 97035 15350 SW SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: 503-747-2503 PHONE:
FAX: 503-972-1861
FEES
Quantity Description Date Amount
5 crt Branch Circuits wo/Purchase 01/24/2020 $85.86
Specifics: Service or Feeder
1 ea Plan Review Electricial 01/24/2020 $21.47
Type of Use: COM 1 ea 12%State Surcharge- 01/24/2020 $10.30
Class of Work: ALT Electrical
Type of Const: 5 Misc Administration Fee 01/24/2020 $5.00
Occupancy Grp:
Total $122.63
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 R 952-001-0090. 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: . '�`z�7�`" Permittee Signature: 7,70/04-)
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
Tigard Received l� __
It City of 1]gill U Date/By: / 1 f / 41 t#C Co1 C.2O—U'wl
13125 SW Ha11 Blvd.,Tigard,OR 97223 PlanReview
Phone: 503.718.2439 Fax: 503.598.1960 DateBy: Z7 ' ✓ Reli&1 (/t+� VZ13-/l
Inspection Line: 503.639.4175 Ready Date y: Juris Bf See Page 2 for
1 1 c;A R I) Internet: www.tigard-or.gov Notified/Method/ 23 fit-- Supplemental Information
TYPE OF WORK V'7«97[L- ai-e-72..i...yeALAN REVIEW
❑New construction 13 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.
❑Demolition ❑Other:
where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
1111-and 2-family dwelling 22 Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 El Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family ❑Master builder 0 Other: 0 Fire pump. ❑Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived
❑Addition of new motor load of system.
Job#: 1 Job site address: 6650 SW Redwood, 190 100HP or more. ❑"A","E","t-z","1-3",
C1 /State/ZIP: ❑Si r more residential units. occupancy.
Ith-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: , Project name: Inte r1 Medical - 0 Hazardous locations. ❑Supply voltage for more than
O ' `� ❑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 4: 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
,i (with above sq.ft.) 75.00 2
e4,-..)?)r)+ I aye-ft-Lava- Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
0 PROPERTY OWNER 1 TENANT Renewable Energy ❑ See Page 2
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: 1 Date: 401 amps to 599 amps 168.54 2
® APPLICANT ❑ CONTACT PERSON Branch circuits-new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: Johansen Electric,Inc. above service or feeder fee,
7.42 2
each branch circuit
Contact name: Charlynn Leifsen B.Fee for branch circuits without
service or feeder fee,first 56.18 �7rs $ 2
Address: 16869 SW 65th Ave#311 branch circuit
City/State/ZIP: Lake Oswego, OR 97035 Each add'l branch circuit `1 7.42 2
Miscellaneous(service or feeder not included)
Phone:( 503)747-2503 1 Fax: :(503 )972-1861 Each manufactured or modular 67.84 2
Email: dwelling,service and/or feeder _
office@johansenelectric.com Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: SAME Sign or outline lighting 67.84 2
Signal circuit(s)
-energy
Address: panel, or
alteration, extension. ❑ See Page 2 2
City/State/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) I 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 Lic.: 51539 I Electrical L -ir, 43C I Suprv.Lic.: 5378S specifically listed(V2 hr min)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: 11 Subtotal:
Print name: Jonathan Johansen Date: elan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: 'L- TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Print name: CkA-Ir A. vl.n— t_pl��� Date: 1 7,07,0 days after it has been accepted as complete.
J C * Number of inspections allowed per permit.
I:\Building\Permits\ELC_PermitApp_ELR=:RE.doc Rev 06/17/2015 440-4615T(11/05/COM/WEB