Permit Electrical Permit Application � N � :��,. FOR ou t ICE• U SE ONLY
74 City of Tigard NF io, I t d , , (�, , fib Permit No.: GL/� /D -e6 a5 -.
4 ; 13125 SW Hall Blvd., Tigard, OR 9722 t' .••- an Review
C Phone: 503,639.4171 Fax: 503.598.1960 / I .0 it *1 � lat e/By: Other Permit:
TIGARU Inspection Line: 503.639.4175 (` V O n t ate Ready /By orris: See Page 2 for
Internet: www.tigard- or.gov C iplibill t+Iatitied/1 ethod: ��n Supplemental Information
41 3® 0 u e ,. p 64
t' -`rm. �Lla- ,� •i a ! 4 ��,�� t a CT .�ne �� !µ'°'
❑ New construction ® Addition /alteration/replacement 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,
0 Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards.
6 . p a ® . 0 . ' M t k , exceeds 10,000 amps at ISO volts or 0 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
pa
a
❑ Emergency system. larger separately derived system.
ag .h it o 0 n 0 0 l ❑ Addition of new motor load of ❑ "A" "B", - I-2", "I-2',"I-3",
Job no.: 62294 Job site address: 16154 SW-t ie a 844111 F nn'cr 44) 1001iP or more. occupancy.
❑ Six or more residential units. ❑ Recreational vehicle parks,
City/State/ZIP: PORTLAND, OR 97224 , su3 72 /" / ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations, 600 volts nominal
Suite/bldg. /apt. no.: I Project name: DOW / DAS REMODEL ❑ Service or feeder 600 amps or more,
VallffirartgaM MOP iitli.; m y .
Cross street/directions to job site: Description Qty. Pee. Total 4
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: I Lot no.: 1,000 sq. ft. or Tess 168.54 4
Tax map /parcel no.: Ha. add'( 500 sq. ft. or portion 33.92
Limited energy, residential 67.84 .2
`s ,. .3' , .; I" �1 :i e a n ' a ` ° . t ',`
' ''tnE . _, ^ (with abuvc s 0.)
VOICE / DATA CABLING Limited energy, multi - family 67 84 - 2
residential (wish above sq. ft.)
Services or feeders installation, alteration, and/or_ relocation
200 amps or less 100.70 2
;k i" ' , ' , n ; , -4 ` a i � ' 201 amps to 400 amps 133.56 2 •
Name: 401 amps to 600 atnps 200.34 2
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: ( ) I Fax: ( ) 200 amps or less 59.36 11
Owner Installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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, er panel t
Owner signature: Date: A, Fee for branch circuits with
% s ti' a -' ' o t x_ ,: ' ' e e Ka •t om ; ':". - , - ' above service or feeder fee,
, "1,P. . hi c Awl*. ni� th . e :. .. M . # T _ c ur w#k ,..1,1„ 7.42 . 2
each branch c
Business name: OREGON ELECTRIC GROUP B. Fee for branch circuits
Contact name: JAMES FITZGERALD without service Or feeder fee 56.18 2
first branch circuit
Address: 1709 SE 3 150 AVE Each add'I branch oircuit 7.42 _2
Miscellaneous (service or feeder not included)
City/State /ZIP: PORTLAND, OR 97214 Each manufactured or modular 67.84 2
dwelling, service and/or feeder
Phone: (503) 234 -9900 1 Fax: : (503) 234 -1001 Reconnect only 67.84 .2
E -mail: Pump or irrigation circle 67.84 2
ry t,. ,:: . sarrwiremmatow vim : i , ! Sign or outline lighting 67.84 2
Business name: OREGON ELECTRIC GROUP signet circuit(s) or limited -
energy panel, alteration, or 67.84
Address: 1709 SE 3" AVE extension. Describe: 1 Page 2 2
VOICE DATA CABLING
City/State /ZIP: PORTLAND, OR 97214 Each additional inspection over allowable In any of the above
Per
Phone: (503) 234 -9900 [Fax (503) 234 -1001 inspection
_ Investigation 66.25
per hour (l hr min) 66.25
CCB Lic.: 203 ?/ 'lectrical, ic 26-'4 Suprv '0.: 48. Industrial plant pper hour
5r�r z"i'f i, 78.18
I A 4„ ,Ott!rl�,:�a;~fga , .' 1.'.. ttka f-' tOW,a,.r., Suprv. Electrician si � ii ' � /, lti i // ITL',ra Subtotal: 67.84
Print name: 4 ' W INB ND Date: 11/9/10
x' Plan review (25% of permit fee):
State surcharge (12% ofpemut fee): 8.14
• Authorize r i i r ./ / j, - TOTAL PERMIT FEE: 75.98
''r :P! ' Date: - ' /10 This permit application expires If a permit is not obtained within 180
Print name: ARK BENDER days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:t Building \Pcrmits\ELC- PermitApp.doe 10/01/09 '140.46!5T(ll /05 /COM/wEB
IN NI
Community Development
TIGARD Request for Permit Action WO
TO: CITY OF TIGARD
Building Division Services Coordinator •rte 0V r1 S 0IA
13125 SW Hall Blvd., Tigard, OR 97223 0�
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov Bv1�'�lly
FROM: ❑ Owner n Applicant n Contractor X1 City Staff
(check one)
REFUND OR Name: f
INVOICE TO: (Business or Individual) N /Q .
Mailing Address: (/ , /
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
jj CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
P •t #: a /O - ooa 5 2
`I 0
Site Address or Parcel #: Rol tj 7AA-4
I, I I�
oil Project Name: ��� TD/9 D / TD/9
1
A ir' 1 Subdivision Name: (or Lot #: �(�}
•
EXPLANATION: U.Jo -A k _ ° I- t, LA-A/ 0
9,0I ,00 P-6I cr
ow Signature: Date: ( \ /17 I o
Print Name: 1 5 €1 4' q s-t -N\
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date tt 1 t o B, 1 Rte to Bldg Admin: Date By
Refund Processed: Date / By ;!�. Invoice Processed: Date By
Permit Canceled: Date Ji � 7 //0 B - r Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \RegPermitAction.doc Rev 07 /26/07