Permit ' ELECTRICAL PERMIT
CITY OF TIGARD
PERMIT #: ELC2004 -00652
��, DEVELOPMENT SERVICES DATE ISSUED: 10/8/2004
�` 13125 SW Hall Blvd.. Tigard, OR 97223 (503) 639 - 4171
PARCEL: 1 S136AD -00603
SITE ADDRESS: 10435 SW 66TH AVE
SUBDIVISION: VILLA RIDGE NO. 2 • ZONING: R-4.5
BLOCK: LOT : 004 JURISDICTION: TIG
Project Description: Installation of (1) branch circuit for new gas furnace.
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL/PANEL:
MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA/SPEC OCC:
Owner: Contractor:
ROBERT ROUNDTREE OWNER
10435 SW 66TH AVE
TIGARD, OR 97223
Phone: 503 - 244 -3271 Phone:
Reg #:
FEES
Description Date Amount
Required Inspections
[ELPRMT] ELC Permit 10/8/2004 $46.85
[TAX] 8% State Surcharge 10/8/2004 $3.75 Rough -
Elect'I Final
Total $50.60
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws.
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
suspend for- re than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those
rule re set forth in R 952-001-001' ough OAR 952 - 001 -0100. You may obtain copies of these rules or • irect questi •ns to OUNC at (503)
246 699 or 1-840-332- � / / /� /
Iss d By: ' • ' / .�L� Permit Signature: `j ' i #
OWNER INSTALLATION ONLY
The installation is being made on property •w whi 'r not intended ; - ale; lease, or rent.
OWNER'S SIGNATURE: (K DATE: O
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N: DATE:
LICENSE NO:
Call 639 -4175 by 7:OOpm for an inspection the next business day
Elect! ' ermit Application FOR OFFICE USE O
City of Tigard Received ' /�'S� PermitNo.: „ /_/ CN 625
13125 SW Hall Blvd., Tigard, OR 97223 Da R
g Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 'y(:}�J � , Date/13 : Other Permit:
Inspection Line: 503.639.4175 ti I Date Ready/By: ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: Wgi Supplemental Information
s "t" P 4 4, ZO t, a, ' ,3-, ,.. r « k v y t rtl: Jg3s-✓ ' .A� . , 7 r
.. . A z;.�" .,.-i .,., � Y 5TYP t OF Rp " b . '"' , .. ,,,r , . - ,,
r '`" 1d 4 a PLAN R , E �K
' y '' 't
❑ New construction ❑ Addition/alteration/replacement Please check all that apply:
❑ Demolition ❑Other ❑Service over 225 amps, comm'l ['Hazardous location
r a s ['Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
LAY. : 1 „µ y . 2,, CATEGORY 9E;.COL+IS RUCTION '` � 1. Vv ,w 'yam 4. of 1- and 2- family dwellings 4 or more new residential
❑ 1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building ❑System over 600 volts nominal units in one structure
❑ Multi - family ❑Master builder ❑ Other: DBuilding over three stories ❑Feeders, 400 amps or more
['Occupant load over 99 persons ['Manufactured structures or
... �. r .tit OB �. !.5W AT150N, s LOGA`TION „�� . ' �.:; r ❑ Egress/lighting plan RV park
�� ❑Health -care facility ❑Other:
Job no.: Job site address: /� l� S� �j� Submit 2 sets of plans with any of the above.
City/State /ZIP: 7 76 , kid g 7 2-7-3 The above are not applicable to temporary construction service.
am * .7. V 7 .. `§ "'
Suite/bldg. /apt. no.: Project name: - d FEEw:.rSFTFDT3LEf , ,. _ .. • !� = LC Description I Qty. Fee. I Total
Cross street/directions to job site: New residential single- or multi - family dwelling unit.
Includes attached garage.
1,000 sq. ft. or less 145.15 4
Subdivision: Lot no.: Ea. add'I 500 sq. ft. or portion 33.40 1
Tax map /parcel no.: Limited energy, residential 75.00 2
n _ Limited energy, non - residential 75.00 2
:A .,. k' : :
, DE5±CRIPTi'UN OFirOR <: t ,�-, ' N' Each manufactured or modular
dwelling, service and /or feeder 90.90 2
(e---,¢ rb C.-A 6/4.r7- f� / -- ze Y Services or feeders installation, alteration, and/or relocation
200 amps or less 80.30 2
❑ PROP,ER1 . s TL1 • bAPIT r , 201 amps to 400 amp 106.85 2
.. -..f' t• : -. _ ,... _ rc . . -. .,.y._ .'.. -..,. . ...+- ; . ..x,.. 14''41":: ' :4 401 amps to 600 amps 160.60 2
Name: 601 amps to 1,000 amps 240.60 2
Address: /7' _5-&„) �/ ,Q��� Over 1,000 amps or volts 454.65 2
^ � �fv Reconnect only 66.85 2
City/State /ZIP: ?6 C2, �� ?7��� Temporary services or feeders installation, alteration, and/or
� 2 / ( ) relocation
Phone: �7 ( Fax: 200 amps or less 66.85 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, re or exc ge, accord' to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 • 2
Owner signature: G Date: l4--8Q Branch circuits - new, alteration, or extension, per panel
` ‘' x *IRLIrls(T i,F a r 1.M5 C O i V42.CTE1LL5Q ` A. A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
Contact name: B. Fee for branch circuits - A ddress:
without service o feeder fee, / 46.85 �6 b �2
eac b ran ch circ
. Each add'l branch circuit 6.65 2
City/State /ZIP: Miscellaneous (service or feeder not included)
Phone: ( ) Fax:: ( ) Pump or irrigation circle 53.40 2
Sign or outline lighting 53.40 2
E - mail: Signal circuit(s) or limited-
.e : ' t; t '" " lr 3 H r panel, alteration
` `.a.. ... x .....- .. , ... , .5 f b1......�"TOR. .. alk ..- ... ,... . __.. 'a .. °si ? ;,:. u
Business name: O_L /0 V extension. energy Describe: , or
Page 2 2
Address: Each additional inspection over allowable in any of the above
Per inspection 62.50
City /State /ZIP: Investigation per hour (1 hr min) 62.50
Phone: ( ) Fax: ( ) Industrial plant per hour 73.75
i t,, r 41s, I, ; t I: , MI r., 'EE5a , •.'T 7 :.;
CCB Lic.: Electrical Lic.: Suprv. Lic.: Subtotal 4.15
Suprv. Electrician signature, required: Plan review (25% of permit fee)
Print name: Date: State surcharge (8% of permit fee) 3. 7S
TOTAL PERMIT FEE 50 . c 0
Authorized signature: This permit application expires if a p ermit is not obtained within 180
days after it has been ac cepted as complete
Print name: Date: • Fee methodology set by Tri- County Building Industry Service Board
•' Number of inspections per permit allowed.
i Building \Permits\ELC- PemtitApp.doc 12/03 440.4615T(10/02JCOM/WEB
Electrical Permit Application - City of Tigard
Page 2 -- Supplemental Information
LIMITED ENERGY PERMIT FEES:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
❑ Audio and Stereo Systems*
❑ Burglar Alarm
❑ Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning
System*
❑ Vacuum Systems*
❑ Other:
ti l•�1 I " .:.:R- ONiitiaR, _I . ..., _ ,07:4
Fee for each commercial system $75.00
(SEE OAR 918 - 260 - 260)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
i:\ Budding \Permits\ELC- PetmitApp.doc 04/03