Permit CITY OF TIGARD ELECTRICAL PERMIT
PERMIT #: ELC2004 -00444
r : i A DEVELOPMENT SERVICES DATE ISSUED: 7/20/2004
�� 1� 13125 SW Hall Blvd.. Tigard, OR 97223 (503) 639 - 4171
PARCEL: 25101 AD -02400
SITE ADDRESS: 12753 SW 68TH AVE 100
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT : 032 JURISDICTION: TIG
Project Description: Office remodel, (2) branch circuits and (1) limited energy for data telecommunications.
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: 1
MANF HMI 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: 1 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:
WESTERN EVANGELICAL SEMINARY GEORGE FOX UNIVERSITY
PO BOX 23939 1101 VILLA ROAD
PORTLAND, OR 97281 NEWBERG, OR 97132 -1218
Phone: Phone: 503 - 554 - 2014
Reg #: ELE 36 -75C
SUP 923S
FEES
Description Date Amount Required Inspections
[ELPRMT] ELC Permit 7/20/2004 $128.50
[TAX] 8% State Surcharge 7/20/2004 $10.28 Low Voltage Inspection
Rough -in
Total $138.78 Elect'I Final
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
suspende - 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those
rules set forth in OAR • - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC at (503)
2 -6699 or 1 -000- 332 -23 A
I sued By: k � �/ Permit 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:
CON - CTOR INSTALLATION Y
SIGNATURE OF SUPR. ELEC'N: 69735 - / d �� �: / DATE: 7 /' /e
LICENSE NO:
Call 639 -4175 by 7:OOpm for an inspection the next business day
E' . ical Permit A lication FOR OFFICE USE ONLY
City of Tigard DD aced r �,�' permit No.: E , . 4/...00 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 /" * 4 Date/B : Other Permit:
Inspection Line: 503.639.4175 _„___ F _ , Date Ready/By: ® See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: r/M Supplemental Information
' PE OF WORK - PLAN REVIEW
❑ New construction Addition/alteration /replacement Please check all that apply:
❑ Demolition Other: ['Service over 225 amps, comm'l ['Hazardous location
. ❑Service over 320 amps - rating ❑ Buildng over 10,000 sq. ft.,
CATEGORY OF CONSTRUCTION • . . of 1- and 2- family dwellings 4 or more new residential
❑ 1- and 2- family dwelling ACommercial/industrial ❑ Accessory building ['System over 600 volts nominal units in one structure
❑Building over three stories ['Feeders, 400 amps or more
❑ Multi - family ❑ Master builder ❑ Other: ['Occupant load over 99 persons ['Manufactured structures or
JOB SITE INFORMATION AND LOCATION ['Egress/lighting plan RV park
Job no.: Job site address: ,4 75 Sz 6, ❑Health -care facility ['Other:
Submit 2 sets of plans with any of the above.
City/State /ZIP: //E >� O,P�-�.J 97223 The above are not applicable to temporary construction service.
Suite/bldg. /apt. no.: l).0 Project name: aere q4 J % FEE* SCHEDULE
Description I Qty. I Fee. I Total I .•
Cross street/directions to job site: �f9/1 / 67 . / 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'l 500 sq. ft. or portion 33.40 1
Limited energy, residential 75.00 2
Tax map /parcel no.: Limited energy, non - residential 75.00 ./ 2
- DESCRIPTION OF WORK • Each manufactured or modular
•
a.../C.- . — ,0VD��� dwelling, service and /or feeder 90.90 2
/ Services or feeders installation, alteration, and/or relocation
----/f-7 7 9 _ 200 amps or less 80.30 2
' RROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
401 amps to 600 amps 160.60 2
Name: Ge0, EX - /q2X U %o / fi t ?ls /rte 601 amps to 1,000 amps 240.60 2
Address: ./ ) 5/A/ /V&/-e/0/4/ti / Over 1,000 amps or volts 454.65 2
Reconnect only 66.85 2
City/State /ZIP: e90— Temporary services or feeders installation, alteration, and/or
Phone:
J Fax: ( ) relocation
(...5) y-- 7 200 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, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 600 amps 133.75 2
Owner signature: Date: Branch circuits - new, alteration, or extension, per panel
❑ APPLICANT ■ CONTACT 'PERSON A. Fee for branch circuits with
service or feeder fee, each 6.65 2
Business name: branch circuit
B. Fee for branch circuits
Contact name: without service or feeder fee,
/
each branch circuit 46.85 2
Address: Each add'l branch circuit 6.65 / 2
City/State/ZIP: Miscellaneous (service or feeder not included)
Pump or irrigation circle 53.40 2
Phone: ( ) Fax: : ( )
Sign or outline lighting 53.40 2
E -mail: Signal circuit(s) or limited-
' • CONTRACTOR . energy panel, alteration, or
• extension. Describe: Page 2 2
Business name: ��Or61/.. � / ‘),.//�G�;,S/,7
Address: .. / / 7 N ' , f Q/ Each additional inspection over allowable in any of the above
/ Per inspection 62.50
City/State/ZIP: a /�� 4 Investigation per hour (1 hr min) 62.50
Phone: (3223 5:5 Fax: ( ) Industrial plant per hour 73.75
ELECTRICAL PERMIT FEES*
CCB Lic.:3 75 ' Electrical Lic.: Suprv. Lic.3 Subtotal
Suprv. Electrician signature, required. dGGC�
Cif Plan review (25% of permit fee) ��(
State surcharge (8% of permit fee) ! ®o to
Print name: /J. CO --,e..1/e‘,./e_ Date: 7 �� 2 ,/
TOTAL PERMIT FEE p r78
Authorized signature: This permit application expires if a permit is not o within 180
days after it has been accepted as complete
Print name: Date: • Fee methodology set by Tri- County Building Industry Service Board
•• Number of inspections per permit allowed.
i:\ Building 1Pennits \ELC•PennitApp.doc 12/03 440- 4615T(10 /02/COM/WEB
Electrical Permit Application - City of Tigard
Page 2 - Supplemental Information
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY: - •
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 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
is\ Building \Pemtiu\ELC- PemiitApp.doc 04/03