Permit (2) t CITY OF TIGARD ELECTRICAL PERMIT
" COMMUNITY DEVELOPMENT Permit#: ELC2019-00845
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/31/2019
Parcel: 1 S136DA00800
Jurisdiction: Tigard
Site address: 11540 SW PACIFIC HWY
Project: Kaleafa Subdivision: FRUITLAND ACRES Lot: 2
Project Description: Electrical for TI:
Contractor: SQUIRES ELECTRIC Owner: HIGH HAT RESTAURANTS, INC
2203 NE MARTIN LUTHER KING JR BLVD 11530 SW PACIFIC HWY
PORTLAND, OR 97212 TIGARD, OR 97223
PHONE: 503-252-1609 PHONE:
FAX: 503-253-5831
FEES
Quantity Description Date Amount
3 ea Services or Feeders-200 12/27/2019 $302.10
Specifics: amps or less
1 ea Services or Feeders-401 to 12/27/2019 $200.34
Type of Use: COM 600 amps
Class of Work: ALT 27 crt Branch Circuits w/Purchase 12/27/2019 $200.34
Service or Feeder
Type of Const: 1 ea Plan Review Electricial 12/27/2019 $175.70
Occupancy Grp: 1 ea 12%State Surcharge- 12/27/2019 $84.33
Electrical
Total $962.81
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Sp ialty Codes and all other ap., able law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days f is-k ance, or if work is su .:nded for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility lAtifi tip Center • ule- :re set forth in OAR
952-001-0010 through OAR 952-001-0090. You ma obtain a c les or direct questions to OUNC by call ng 5 :2.1987 or .:00.33
Issued By: n--. Permittee Signature:
4111111
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 ry .' FOR OFFICE USE ONLY •
City of Tigard t Received 4 '
C lJ Q -• r �_ _
III • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review Jr / / , /
Phone: 503.718.2439 Fax: 503.598.1960 Date/B : /-. e e
Inspection Line: 503.639.4175 Ready Date/By: / ® See Page 2 for
TIGARD, Internet: www.tigard-or.gov Notified/Method:{f ,1 A HIM Supplemental Information
TYPE OF WORK PLAN REVIEW
❑New construction DaAddition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
*Service or feeder 400 amps or more 0 Building over three stories.
0 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 Commercial/industrial 0 Accessory building less to ground or exceeds 14,000 0 Commercial-use agricultural
14 amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ['Emergency system. larger separately derived
_ � , ❑Addition of new motor load of system.
Job#: Job site address: l� Sip 5 W N.C.:F I e +,
. 1 +� 100HP or more. ❑"A","E 'l-2 "I-3
❑Six or more residential units. occupancy.
City/State/ZIP: 1-f61t(d t (J t2 0 Health-care facilities. 0 Recreational vehicle parks.
SuitePoldg./apt.#: Project name: " k{ sCf�"( / Ito;
c Hazardous locations. 0 Supply voltage for more than
�t 600 volts nominal.
Ll� Scrvtce or feeder 600 amps or more.
Cross street/directions to job site: co 711. 4cusi c iR M-t41 ',;; .' FEE SCHEDULE
Description I Qty. I Each I Total I *
5 W 04 T, 'mtYsu-ii-!'t' 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
y�
(with above sq.ft.) 75.00 2
(pOGNOt Se-ot1CL CD 4" 3x 2-oop Qpw.Q,p'32A- :sre- oc Limited energy,multi-family 75.00 2
b V '\Gl,l Car 3 -�-rn,�a.._-1'Sy2•e..-S residential(with above sq.ft.)
'� Renewable Energy ❑ See Page 2
0 PROPERTY OWNER ❑ TENANT Services or feeders installation,alteration,and/or relocation
Name:
200 amps or less 3 100.70 3o2.14 2
Address: 201 amps to 400 amps 133.56 2
' 401 amps to 600 amps I 200.34 Z OU-31 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 El PERSON Branch circuits—new,alteration,or extension,per panel
Pr A.Fee for branch circuits with
Business name: 4,4 above service or feeder fee, .L7 7.42 2 W-34 2
each branch circuit
Contact name: B.Fee for branch circuits without
service or feeder fee,first 56.18 2
Address: branch circuit
City/State/ZIP: Each add'I branch circuit 7.42 2
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: S1 v�!g5 ��GL``^�e . Z✓t L Sign or outline lighting 67.84 2
U Signal circuit(s)or limited-energy 0 See Page 2 2
Address: q� S�IN �f p y` c - panel,alteration,or extension.
City/State/ZIP: ��� I 0 Each additional inspection over allowable in any of the above
tyAdditional inspection(1 hr min) 66.25/hr
Phone:61)3) 6- -_1(,,QC} : (j1 ) --.—5V9 Investigation(I hr min) 90.00/hr
Email: 'Ilea `�,! /! Industrial plant(1 hrmin) 78.18/hr
S 1/iYGS !/ ff/(( [ Inspections for which no fee is
13 S0 S S-- - 1 specifically listed(/hr min)
90.00/hr
CCB Lic.: Electrical �� Suprv.Lic.: 4.30 2�5
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: —70 2.78
Print name: J o C S v.rt S
Date: IS Plan Review Required(25%of permit fee): 1 75,70
State surcharge(12%of permit fee): 64-33
Authorized signature: _ TOTAL PERMIT FEE: 9 to 2-b
This permit application expires if a permit is not obtained within 180
Print name: \ V L S w x�e-S Date: i 1,(4 f (1 days after it has been accepted as complete.
J * Number of inspections allowed per permit.
I:tBuilding\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 445-4615T(II105/COM/WEB