Permit Support Document 71f,
CITY OF TIGARD ELECTRICAL PERMIT
II COMMUNITY DEVELOPMENT AILPermit#: ELC2020-00033
C` ' t .' Date Issued: 01/22/2020
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503,718.2439
's'. .. Parcel: 2S104AA07500
WI' " ' • Jurisdiction: Tigard
Site address: 12725 SW BUGLE CT
Project: Palomino Subdivision: BELLWOOD NO.2 Lot: 110
Project Description: (1)branch circuit for replacement of(3)exhaust fans. 1/22/20: REPRINTED to correct address.
Contractor: D & M ELECTRIC LLC Owner: PALOMINO,ANDRES&JENNIFER
19520 FALCON DR 12725 SW KATHERINE ST
OREGON CITY, OR 97045 TIGARD, OR 97223
PHONE: 503-577-6315 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 01/22/2020 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 01/22/2020 $6.74
Type of Use: SF Electrical
Class of Work: ALT
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
Issued B ,a._—ye.- __ may rvY -,ti>=,py Permittee Signature: g <z` a2.2344.M1
9 2-001-0010 through OAR952-001-0090. You obtain a co oftherules or direct questions to OUNCbycalling 503.232.1987 or 1.800.
Y
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 ()NIA
City of Tigard RECEIVED Received , '
111‘ Date/B : / 4,, „Au. �� u
a 13125. SW Hall Blvd.,Tigard,OR 97223 Plan Review
II Phone: 503.718.2439 Fax: 503.598.1960 AN 2 1 202� DateB : IRIIMI
Related Permit#:illG_ y `Ill to P
Inspection Line: 503.639.4175 Ready Date/By: H See Page 2 for
T I G A R D Internet: www.ti and-or. ovNotified/Method: Supplemental Information
g g CITY OF TIGARD t PP
TYPE OF Wailgi.DING t.IViSiO�v PLAN REVIEW
0 New construction Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
O 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.
1-and 2-family dwelling 0 Commercial/industrial ❑Accessory building Multi-family ❑Master builder ❑Other: less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION 8 0 Emergency system. larger separately derived
Job#: Job site address: OC a W LT ❑Addition of new motor load of system.
1 I OOHP or more. ❑"A","E","1-2","1-3",
. ):1'
❑Six or more residential units. occupancy.
City/State/ZIP:
Tywr,I. be cr.-7 2,zt/ 0 Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: 1 Project name: 1?, NO 0 Hazardous locations. 0 Supply
lolts voltage for more than
0600 Service or feeder 600 amps or more.
Cross street/directions to job site: FEE SCHEDULE
Description 1 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'1500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
75.00 2
Rep`eA(t��- + O (3)
x �5 f �1 (with above sq.ft.)) {"f�I/1 Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Renewable Energy 0 See Page 2
0 PROPERTY OWNER 1 0 TENANT Services or feeders installation,alteration,and/or relocation
Name: A- r /} 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
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
1 ltrt t"f i L �� 1' iii" each branch circuit
Contact name: G`.i te, 1 � �\V li C B.Fee for branch circuits without
"""G //�� 1 ,t� service or feeder fee,first
Address: !ti5j raltel^ Dar Q��r,,\0- branch circuit 56.18 1 2
y W 6 Each add'l branch circuit 7.42 (� 2
City/State/ZIP: D G 64'47 O� cJ?V[L/S )
✓(� , Miscellaneous(service or feeder not included
Phone:(Cob) S-7-(0 31 c Fax::( ) Each manufactured or modular 67.84 2
Email: T'@A dwelling,service and/or feeder
l7 (6p,yl,�,. P/'v-,�- 1 t�f '.' "s✓1 j, ,4 , f ^"i:t,4 Reconnect only 67.84 2
� 1 CONTRACTOR Pump or irrigation circle 67.84 2
Business name: ig j 4—....,—I ''L.. w Sign or outline lighting 67.84 2
;V
Signal circuit(s)or limited-energy ❑ See Page 2 2
Address: I Ci ca0 i.(tt v. f)�. panel,alteration,or extension.
City/State/ZIP: 64.4..1e^7 / Each additional inspection over allowable in any of the above
Oln G 137 , (2_ a `0'GS Additional inspection(1 hr min) 66.25/hr
Phone:(SQ1)) 57 7_/03( ' Fax:( ) Investigation(1 hr min) 90.00/hr
Email: 670(1414 _ D —Ll' fi(_t hl1ikt a N/t Industrialsco s plant which(1 h no) 78.18/hr
��aa Inspections for fee is 90.00/hr
CCB Lic.: �l 8 3(5' Electrical Lic.: 11 'Sdpr?.Lie.: Sf Ai` specifically listed(%hr min)
/ ELECTRICAL PERMIT FEES
Suprv.Electrician signai&ti,re Fred: ii Lo 1 Ir' Subtotal:
Print name: &A,02/4./J fl DeriSc ) Date: /-2/1 2.40 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
TOTAL PERMIT FEE:
Authorized signature: (�
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_•ermitApp_ELR_ERE.doc Rev 06/17/2015 440-4615T(l1/05/COM/WEB