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CITY OF TIGARD ELEzTRIonL PEM1IT
COMMUNITY DEVELOPMENT DEPARTMENT
13125 SW Hall Blvd. Tigard, Oregon 97223'8199 (503) 6394171
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4- `' Community Development ELECTRICAL PERMIT APPLICATION
13125 SW Hall Blvd.
Tigard, OR 97223 Permit # ELC q6 - O I g7
*A\ Date Issued y - 46
"''` I Phone (503) 639 -4171
FAX (503) 684 -7297
CITY OF TIGARD TDD No. (503) 684 -2772
Inspection (503) 639 -4175
1. Job Address: -�1 , f I Pal it 4. Complete Fee Schedule Below:
Name of Development i li�J4 Pl IW t v6V EJ Number of Inspections per permit allowed
Address 14140 SW 72nd Ave. 41100 Service included: Items Cost(ea) Sum
City /State /Zip Tigard, OR 97224 4a. Residential - per unit
1000 sq. ft. or less $110.00 4
Name (or name of business) Tech Poulson Each additional 500 sq. ft. or 525.00
portion thereof
Commercial ® Residential ❑ Limited Energy 525.00 1
Each Manuf'd Home or Modular
Dwelling Service or Feeder 568.00 2
2a. Contractor installation only:
4b. Services or Feeders
Electrical Contractor g I
Electrical nstallation, alteration, or relocation
Ore green ectrical Const. 3 .0.00 lima 2
2 amps or less
Address 10260 SW Nimbus Ave. M -12 201 amps to 400 amps - 580.00 2
City ortland Stat OR Zip 97223 401 amps to 600 amps $120.00 2
Phone No. 620 -7952
ty P - 2 - $180.00 MU . UU
Over amps to amps amps = $340.00
Over 1000 amps or volts 14 2
Job NO. Reconnect only 550.00 2
contractor's license NO. 34 -86C 4c. Temporary Services or Feeders
Contractor's Board Reg. No. - 42305 Installation, alteration, or relocation 2
Signature of Supr. Elec'n - . 200 amps or less 2
License No. 2423S Phone No. 620 -7952 201 amps to 400 amps 550.00
401 amps to 600 amps 575.00 2
Over 600 amps to 1000 volts 5100.00
2b. For owner installations: see "b" above.
4d. Branch Circuits
Print Owner's Name New, alteration or extension per pane
Address a) The fee for branch circuits with
purchase of service or feeder 2
City State Zip Each branch circuit 123 E5.00 615.00
Phone No. b) The fee for branch circuits without
The installation is being made on property I own which is purchase of service or feeder fee. 2
not intended for sale, lease or rent. First branch circuit 535.00
Each additional branch circuit 55.00
Owner's Signature 4e. Miscellaneous
(Service or feeder not included) 2
3. Plan Review section (if required): Each pump or irrigation circle 540.00 2
Each sign or outline lighting 540.00
Signal circuit(s) or a limited energy 2
Please check appropriate item and enter fee in section 5B. panel, alteration or extension $40.00
4 or more residential units in one structure Minor Labels (10) 5100.00
X _ Service and feeder 225 amps or more
System over 600 volts nominal 4f. Each additional inspection over
Classified area or structure containing special occupancy the allowable in any of the above
as described in N.E.C. Chapter 5 Per inspection $35.00
Per hour $55.00
In Plant $55.00
Submit 2 sets of plans with application where any of the above
apply. Not required for temporary construction services. 5. Fees:
5a. Enter total of above fees $ 1, 735.00
NOTICE 5% Surcharge (.05 X total fees) $ ob./5
PERMITS BECOME VOID IF WORK OR CONSTRUCTION Subtotal $
1t
5 b. Enter 25% of line A for
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR Plan Review if required (Sec.3)
A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS Subtotal $ 2,2/1.19
COMMENCED. wordlcomdeNe3eF ❑ Trust Account #
$
Prm.aPP
Balance Due
aas -. St)
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line: 639 -4175 Business Phone: 639 -4171
Footing Rain Drain Cover /Service FINAL:
Foundation Water Line Ceiling - Plumb.
Post/Beam Mech. Shear /Sheath Framing -Mech.
PIbg.Und /FIr /Slab Plbg. Top Out Insulation - Elect.
Post/Beam Struct. Mech. Rough -in Gyp. Bd. -Bldg.
San. Sewer Gas Line Appr /Sdwlk Reins.
Other:
Date: j f A.M. f-r4., P.M. Entry:
Address: / y ) f e t> 7?
Tenant: :eti— pct 5 .' — Ste: MST:
BUP:
Con /Own:(90 -- g1( P t2 MEC:
Fe0 - 75'c...3 ELC: - ag4! P '
THE FOLLOWING CORRECTIONS ARE REQUIRED: ELR:
C.. ; /( 7 e _ e 0 c) e 1 ---
Inspector: 1 _ .• - - '4i, Date:, 7
APPROVED _ DISAPPROVED /CALL FOR REINSP. CF CO