Permit CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2010 -00121
TEGRD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 03/16/2010
A
Parcel: 2S111BD01503
Jurisdiction: Tigard
Site address: 14945 SW 98TH AVE
Subdivision: ALDERBROOK FARM Lot: 6
Project: BREITENSTEIN
Project Description: Reconnect.
Owner: FEES
BREITENSTEIN, MARGARET Quantity Description Date Amount
14945 SW 98TH AVE
TIGARD, OR 97224 1 ea Reconnect Only 03/16/2010 $67.84
PHONE: 503 244 -7754 1 ea 12% State Surcharge - 03/16/2010 $8.14
Electrical
Contractor:
ROBERTS ELECTRIC INC
5759 SW 48TH ST
PORTLAND, OR 97221
PHONE: 503- 244 -7754
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $75.98
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: 13\ C LL(\ QA Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Q APp`. C -Ce ) r . OYN Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
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Electrical Permit Application ' r ;' " , ,-ki of , ovi 1(� I. ON k in v r a ,(14 :
, --r +. �'',= r Received p � i
tY% t Date /By: �I$V ®� �Igal (� `,�! I Permit No e r � c'Q •6G,,
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review y {
!`,• C . Phone: 503.639.4171 Fax: 503.598.1960 Dat /By: Other Permit:
Inspection Line: 503.639.4175 Date Read /B lu ris:
r p Ready /By: VI See Page 2 for • b � 0 Internet: www.tigard or.gov Notified /Method: ` q Supplemental Information
r.. � Lam]
TYPE OF WORK PLAN REVIEW
❑ N ew construction Please check all that apply (submit 2 sets of plans w /items checked below):
❑A ddition /alteration /replacement
❑ Service or feeder 400 amps or more ❑ Building over three stones.
❑ Demolition 0 Other:
where the available fault current ❑ Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings.
less to ground, or exceeds 14,000 ❑ Commercial -use agricultural
❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system.
❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ", • Job no.: Job site address: G'r'' / ?ac >":=- 10OHP or more occupancy.
j � - 11r ❑ Six or more residential units. ❑ Recreational vehicle parks.
-' — , _ j ❑Health -care facilities . ❑ Supply voltage for more than
City /State /ZIP: ". - ^ 2' . ,,, -, -'i ` > 7 • 0 Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: • Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: -/ -/' ✓' �'
. - -4- ■ , / ;l / r �. f ; i •: /�,. � - i " %''' Description l Qty. I Fee 1 Total
' New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: -
Limited energy, residential 67.84 2
DESCRIPTION OF WORK (with above sq. ft.)
Limited energy, multi - family
r ..p . , co C\ r\--Q_EA On. 1 L.,_ residential with above sq ft. 67.84 2
Services or feeders installation, alteration, and /or relocation
200 amps or less 100.70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2 .
Name:
• 601 amps to 1,000 amps 301.04 2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP:
relocation
Phone: ( ) Fax: ( ) 200 amps or less 59.36 1
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A Fee for branch circuits with
❑ APPLICANT ❑ CONTACT PERSON above service or feeder fee 7 42 2
each branch circuit
Business name: B Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: branch circuit
Each add'I branch circuit 7.42 2
Address: Miscellaneous (service or feeder not included)
City /State /ZIP: Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only I 67.84 2
Pump or irrigation circle 67.84 2
E -mail:
Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) orlimited- energy
. II ^ panel, alteration, or extension. I Page 2 2
t+t ,/,i
Business name. f �r , j> ,rrr
' � J � - • / ` 1� Each additional inspection over allowable in any of the above
Address: 5 l�f : e /4/ 4' e Additional inspection (1 hr min) 66.25/ hr
/ Investigation (1 hr min) 66.25/ hr
City /State /ZIP: b - .. �:/ ', 72.1
_ � Industrial plant (1 hr min) 78 hr
Phone: ( ) ) 7 t / -' f Fax: ( ) Inspections for which no fee is 90 / hr
, ` a 7 specifically listed (/2 hr min)
CCB Lic.9' Electrical Lic.: >
-Z 3 . Suprv. Lic 316,5 ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: p I �, o Subtotal:
� i t r, Plan review (25.0 of permit fee):
Print name: Date: State surcharge (12% of permit fee):
TOTAL PERMIT FEE: 7 5, 9
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.
1 its \ELC -Perm it App doc 10/01/09 440- 4615T(I I/05 /COM/WEB
T � Request to Energize an Electrical Installation lo-2_010 n121 ci
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REQUESTING SUPERVISING ELECTRICAN INFORMATION
Name of supervising electrician: et 1012(..k- E rY-t a C� (. Date of request: .3 i I c I O
Supervising electrician's license number: 3(;),8( Date installation was completed: 3 /1(4i i 0
Electrical permit no.: E. e.2.c a. m 12,' if a temporary permit is posted at the job site, please include a copy of it with this form.
EMPLOYING ELECTRICAL CONTRACTOR INFORMATION
Name of electrical contractor: Q *) ' -\-- �Q(' , \Y t, c l n C_ License no.: CI "E�
Business address: 5 sc LA ' n A, ,e
City: Qc(*Vax-v3,, State: g f2 ZIP: g. . ■
Phone: `,3p_' - -a414 71 54 Fax: - - E -mail:
CUSTOMER INFORMATION
_ 6���
Customer's name: ^ I$e//zS '
Customer's • ddress: , l/(' I VC SW * G � /
City: , ' Al State: ZIP:9 f�
Address df i • stallation if different than customer's address:
City: State: ZIP:
INSPECTING AUTHORITY INFORMATION
Authority having jurisdiction to inspect: 0 ( ( -4 T %cc r d Phone:5Q3 - ac{ 3 9
Address: 1 ,, 1 ZS S In; c.. (,l Vol
City: l ;_n. G{ State: ZIP: 4���.3
`�� RECEIVING ELECTRIC UTILITY INFORMATION
Name of electric utility receiving request: Phone: - -
Address:
City: State: ZIP:
REASON FOR REQUEST
A. Restoring electrical service that was interrupted or disconnected because of either a:
❑ Service change or "Uncontrollable event, such as fire, flood, or severe weather;
or
B. Electrical service at a remote location needs to be:
❑ Initialized Restored
COMPLETION INSTRUCTIONS AND SIGNATURE
Supervising electrician Electrical contractor
Note: After sending this form to the electric utility Note: By close of business on the first business day following
named above, you must send a copy of this form to: energizing of a completed installation in response to the above
(1) the electrical contractor, (2) the customer, and request, you must: (1) notify the authority having jurisdiction
( insecting authority. that the installation has been energized, and (2) request that the
M dt- 16 2fl /D authority inspect the completed installation.
Supervising electrician's signature Date Electric utility
Note: Please consider notifying the inspecting authority
K identified in this request when an installation is energized
Ito 7 t bfit DEPARTMET F
K CONS S UM R
I-, ,EE1W S
440- 0948 -COM (10 /08 /COM