Permit S.) '11,0 arAokei C() - i - e--Q cc-r ci 0) , r�4 -
• CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2010- 00332
:TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/02/2010
Parcel: 1 S136DD00700
Jurisdiction: Tigard
Site address: 11535 SW 67TH AVE
Subdivision: WEST PORTLAND HEIGHTS Lot: 3
Project: Health Physics Northwest
Project Description: (1) 200 amp service for X -ray equipment. 8/04/10 added (1) feeder and (1) branch circuit B.T.
Owner: FEES
HEALTH PHYSICS NORTHWEST Quantity Description Date Amount
11535 SW 67TH
TIGARD, OR 97223 1 ea Services or Feeders - 200 07/02/2010 $100.70
amps or less
PHONE: • 1 ea 12% State Surcharge - 07/02/2010 $12.08
Electrical
108 da Electrical Permit 08/04/2010 $108.12
Contractor: 13 da 12% State Surcharge - 08/04/2010 $12.97
HARVEY ROSE ELECTRIC SERVICE Electrical
PO BOX 128
NORTH PLAINS, OR 97133
PHONE: 503 - 789 -3284
FAX: 503 -648 -8254
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
•
Total $233.87
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 = • - •y the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0100. Yo - • • .. = •• • • I -ct questions to OUNC by calling 503.2 .6699 or 1.800.332.23
Issued By: �i1� - = i�� Permittee Signature: '1
��
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 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.
•
CITY OF TIGAR® ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: ELC2010 00332
13125 SW ' H all Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/02/2010
I1�i4 Ft Parcel: 1 S 136DD00700
Jurisdiction: Tigard
Site address: 11535 SW 67TH AVE
S ubdivision: WEST PORTLAND HEIGHTS Lot: 3
Project: Health Physics Northwest
Project Description: (1) 200 amp service for X -ray equipment
Owner: FEES
HEALTH PHYSICS NORTHWEST Quantity Description Date Amount
11535 SW 67TH
TiGARD, OR 97223 1 ea Services or Feeders - 200 07/02/2010 $100.70
amps or less
PHONE: 1 ea 12% State Surcharge - 07/02/2010 $12.08
Electrical
•
Contractor:
HARVEY ROSE ELECTRIC SERVICE
PO BOX 128
NORTH PLAINS, OR 97133
PHONE: 503 - 789 -3284
FAX: 503 - 648 -8254
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $112.78
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 Iew 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 246.669 or 1.800.332.2344.
Issued By: M Permittee i97°/oL " L41-77c.k
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 SIJPR. ELEC' 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.
Electrical Permit Application � Recei
V° FoR ( l lc E lisle: um.)`
�i
114 City of Tigard
3, C� DateB ved : U Permit No .: ^ L �„ —
° 13125 SW Hall Blvd., Tigard, OR 97 r Q Plan Review
' 17 • Phone: 503.639.4171 Fax: 503.598.1960 \ �. 0 A 1- Date/B : Other Permit:
1 . 1 A RI) Inspection Line: 503.639.4175 P`' 1 AO Date Ready/By: ® See Page 2 for
Internet: www.tigard or.gov �� INCj l N Supplemental Information
TYPE OF WO RD - �� ��, C O N a PLAN REVIEW
❑ New construction ❑ Addition/alterati Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more ❑ 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.
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 ", "I -3 ",
Job no.: Job site address:
-'� 10OHP or more. occupancy.
/5 Ci..) . �/ 7 0 Six or more residential units. 0 Recreational vehicle parks.
City /State /ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than
, IL �I� . AAA), ❑ Hazardous locations. 600 volts nominal.
/
Suite/bldg. /apt. no.: Project name: pi,, ❑ Service or feeder 600 amps or more.
• - FEE SCHEDULE
Cross street/directions to job site: Description 1 (Bv. 1 Fee. 1 Total 1-
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1
Limited energy, residential
DESCRIPTION OF WORK . (with above sq. ft.) 75.00 2
Limited energy, multi - family 75.00 2
OO1/4 1 tNN) ( \ , G ) b s \ c r � �� 6 � residential (with above sq. ft.)
�L J J Services or feeders installation, alteration, and/or relocation
200 amps or less 1 100.70 /� - 70 2
❑ PROPERTY OWNER 1 ❑ 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
City/State/ZIP: Temporary services or feeders installation, alteration, and/or
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 401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits — new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
•
above service or feeder fee
❑ APPLICANT ❑ CONTACT PERSON fee,
/ 7.42 7 . to 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
ilif 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
ty dwelling, service and/or feeder
Phone: ( ) Fax:: ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E - mail: Sign or outline lighting 67.84 2
CONTRACTOR Signal circuit(s) or limited- energy
Business name: panel, alteration, or extension. Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr
specifically listed (%2 hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: o Subtotal: . \
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): 1 • 0/
TOTAL PERMIT FEE: i t- \ t C) l
Authorized signature: This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: Date: * Number of inspections allowed per permit.
1:\ Building \Permits\ELC- PermitApp.doc 07/01 /10 440- 4615T(11/05/COM/WEB
FROM :BARBAR'SaROSEELEC" FAX NO. :51+,1488254 Jul. 01 2010 11:13AM P1
Electrical Permit Application q� " �� ' x` 1
_ .. _ . W 1: - �n ....rnw 1 at• ,.. 4`, i - .!t , ,. 1;�n v� .., -.:, , a4 „ w.
�f I
trq i t � ^ ervrd . /A. Perm No.'
�„ city of Tigard 0�0 Received / o 4 Ec c°zdro - a' - '
. " s 131.3 5 - Ha ll' 131vd T Lin- , OR 97223 ''°
R acs Revic
•
5 , Phone 503 639 4171 �� Fax- 503.598.1960 , r�flw Other;Pnrmit
ti
. ` ` M° Inspection Line: 503 639.4175 "f \v at ReadyBy: - Jwix fa Seeaee 2. for M
1Tl l(,ARUr P ON s S ti o Qiotit tied/Mettiod T A k iP
4upplemental'Informatioo
m44,4' >: ,; Internet: www:ugard= or.gov \ .� � �
'TYPE OF WORK ... \ \UP
PLAN REVIEW •,:.. • .; ' .:4:; ::'.15 :::
v Pleas check at appy {s se ta o pin
k all that 2 f w /iterrrs checked h& ')
O'New construction _: Addition /alteration/rcp11 anent
❑ Service or feeder 400 amps or tn0re ❑ Building over thrnc;sWt ies.
❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyard%.
CATEGORY OF CONSTRUCTION exceeds 10,000 snips at 150 volts or 0 Floating buildings.
less 10 ground, or exceeds 14,000 ❑ Commercial -use agricuhual
0 1- and 2- family dwelling lil2`.ommercial /industrial ❑ Accessory building amps for another installations. buildings
❑ Multi - family 17 Master builder ❑ Other: El Fire pump: ❑ installation of 75 KVA or
-. ❑ Emergency system. !anger %eearatcly derived system.
JOB SITE INFORMATION AND LOCATION' 0 Addition of new motor bad of
1 100HP or MOM, tweupa It y.
Job no.: Job site address: 4 5 3 5 S r Cn -1 4-"1 ❑ Six or more residential uvits. ❑ Recreational vehicle parks.
C it �Stnit (Zli': I"� Q 7 Z 3 [] Health-care facilities. 0 Supply voltage for mute than
Y / i 04 - e?' , ! _ El Hazardous locations, 6 0 writ% nominal.
Suite /bldg. /apt. no.: Project name: V feeder 600 amps or more.
/ p Service or fend FEE SCHEDULE. .
Cross street/directions to job site: 5 (,,) E t//p < J 5 Path Nu. Fe To -
I Ncw rcridentiat single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: I,OOOSq. t3. or less 145.15 4
__ • - Ealadii'I 500 sq. 11 or portion 33.40 1
Fax map /parcel no - : ' Limited energy, residential 75.00 '
DESCRIPTION OF WORK .; ty. .. , ' (with abovcsq, ft )
— - Limited energy, multi- family 75.00
• _
00 t2 $ �, c h F or X r ra 4� e ' (J f / 1(e residential (with above sq; fl,) 1 2 Services or feeders installation, alteration, and/or relocation" •
200 amps or less 80.30 :0.1 I 2. •
B PROPERTY OWNER ❑ TENANT • • • • ' • 201 amps to 400 amps 106.85 1111 2
Nome:. / /f ph , 1 dr4Wa. 401 amps to 60 0 am ps 160.60 z
601 amps to 1,000'atups 240.60 2
Address. l 5 3 S 5' W - } Over 1,000 amps or volts 454.65 2
City /State /LIP: 1 i,„... c o 9 2 3 Temporary services or feeders installation, alteration, and/or
relocation
Phone: ( ) 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
intended for sale. lease,,rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133,75 2
Branch circuits - new or extension, . er,panel
Owner signature: Date: A Fce for branch circuits with
APPLICANT: El CONTACT PERSON' : :. : `.. • above service or feeder fee,
each branch Circuit 6:65 2
Business name:
B. Fce for branch circuits
Contact name: without.service or feeder fee,
first branch circuit 46.85 2
Address: Each add`I branch circuit MINIM City /Stale /GIP:
Miscellaneous service or feedernofincluded 2
' ---� Each muftictu
Phone: ( ) Fax:: ( ) dwcllin_ art service red and/or or rnodulsr feeder 90.90 � a
L-;_nteil: Reconnc r 66.85
CONTRACTOR Pumper irrigation Circle 53.40 MEM
I3usiness name: Sign or outline lighting MI 53.40 4
O ✓V C " / 5e /l cf // Signal circuit(s) or limited-
, SEv7 �` panel, alteration, or
Address' j S energy - 'a extension. Describe: Page 2
City /Sttllc /7.1Y: ,Gti /. ph,,, "'—r
D, r R3 Each Additional ilia , action over allowable uu an of the above
Phone: ($�'� 41 P , S- u 1 • i 62 50
t r CCB Lie.:L4 3 0 9 / vesuyation per hour (I hr thin) 62.50 � �
Y fi lcctr ical Lic. 3 3 Suprv. Lic,: ,�75 industrial plant perhour MO r
Print name:
Suprv. Electrician signature, required: �
r lul5lotal; e ��
, - , Date Plan review (25 "/, of perrnit fee }: / U 1 ,
Authorized signatures State surcharga (I2 °6 ofpen fie } : d
�,. TOTAL FERMiT FEE: eq.
Uatd: Tbi4.pe Application cx i re, i f a e
Prihuiarrrc
�� a c rote td c I n. 1$0
— days after it has boon accepted a% o o m ph e_
r■8uildinglPerntits\CLC.PermirAli ., a 05/21A* ' Number of inspections allowed per permit. �/ �
44D•46 15T(l, /o5 /CUM/w6H // �1 / "
•
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information .
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORKONLY:
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:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918- 309 -0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
n Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
❑
•
Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other
Total number of commercial systems:
. *No licenses are required. Licenses are required
for all other installations
I: \Building\Permits\ELC- PermitApp.doc 07/01/10