Permit CITY OF TIGARD ELECTRICAL PERMIT
IL
COMMUNITY DEVELOPMENT Permit #: ELC2010 00673
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718,2439 Date Issued: 12/07/2010
Parcel: 2S110DD11100
Jurisdiction: Tigard
Site address: 15530 SW 109TH AVE
Project: Messick Subdivision: SUMMERFIELD NO. 13 Lot: 681
Project Description: Panel replacement.
Contractor: OWNER Owner: MESSICK, WARREN &
PATRICIA C
15530 SW 109TH AVE
TIGARD, OR 97224
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 12/07/2010 $100.70
Specifics: amps or less
1 ea 12% State Surcharge - 12/07/2010 $12.08
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $112.78
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 through OL_.r- 2- 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: �/ Permittee Signature: - _ / i /g�� ,���
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Application • FOR OFFICE U SE ONLY
I G A R D Inspection Line: 503.639.4175 Of Tigard
Received '_ permit No.: u )1, Tigard DateB : 7
° City 13125 SW Hall Blvd., Tigard, OR 97� Plan Review
C \ \\%
Other Permit:
Phone: 503.639.4171 Fax: 503r59$.1960� ,11. DateB
•f p9 r10 Date Ready /By: Juris: ® See Page 2 for
Internet: www.tigard- or.gov G p t • N Supplemental Information
TYPE OF WO G Q\V PLAN REVIEW
❑ New construction
^l l � v") Please check all that apply (submit 2 sets of plans w /items checked below):
A ddition/alterati g rl� , rep m �`t�
v \�\ ❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition • ❑ Other: et \ \L O 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
1111- 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 ", "l -2 ", 't -3 ",
Job no.: Job site address �r- ) , ? 22 =-4- 0 -( , I I , 100HP or more. occupancy.
��j J t/�" ` v ❑ Six or more residential units. ❑ Recreational vehicle parks.
City /State /ZIP: ❑ Health -care facilities. ❑ Supply voltage for more than
❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: I Project name:k5 / r—� /, ❑ Service or feeder 600 amps or more.
�/ °{ / FEE SCHEDULE
•—!
Cross street/directions to job site: it/€Pr/ /l"4tit /,er se Description 1 Qty. I Fee. 1 Total I "
New residential single- or multi - family dwelling unit.
,C/71G44 �� Pre- / Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.:
Limited energy, residential 75.00 2
DESCRIPTION OF WORK (with above sq. ft.)
r ` `�`1 `1
/� Limited energy, multi - family 75.00 2
060 A ') j
p . ' //� N/e residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less / 100.70 (( Y3 70 2
PROPERTY OWNER .❑ TENANT 201 amps to 400 amps 133.56 2
/ 401 amps to 600 amps 200.34 2
Name: R ��/ e f igT�2 /G! A l 6 E'SS//
�/ / P/ v � 601 amps to 1,000 amps 301.04 2
Address: /5 3 / S W • /D y 7`• Avt-. Over 1,000 amps or volts 552.26 2
Cit City/State/ZIP: Temporary services or feeders installation, alteration, and /or
Y �A,4,ep / 4R ce4tOh� T 7Z24- relocation
200 amps or less 59.36 1
Phone: (`JO.3) („e - 1915 Fax: ( )
201 amps to 400 amps 125.08 2
Owner ins all. t ' his installati • r.g made on property that I own which is not
intended fo • . l* o - • • cording to.0' ' 447, 449, 670, and 701. 401 amps to 599 amps 168.54 2
Branch circuits — new, alteration, or extension, ter lane!
Owner si, . . _,...,...-__:1 „dd.; i ", . - Date: /2-7-/G A. Fee for branch circuits with
❑ APPLICANT 1 ❑ CONTACT PERSON above service or feeder fee, 7 42 2
each branch circuit
Business name: B. Fee for branch circuits without
service or feeder fee, first 56.18 2
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
Y 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
C t..tJAh ° 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 (% hr min)
CCB Lic.: Electrical Lic.: Suprv. Lic.: ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal: lo
Plan review (25% of permit fee):
Print name: Date: State surcharge (12% of permit fee): 1) (J
TOTAL PERMIT FEE: ft? .
Authorized signature: This permit application expires if a permit is not obtained within 180
Print name: Date: days after it has been accepted as complete.
Number of inspections allowed per permit.
l:'Building\Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(1 l /05 /COM/WEB
e r{Da r/
Electrical Permit Application - City of Tigard / °G -70
Page 2 - Supplemental Information t "Z 7
/ /2-7Y
LIMITED ENERGY PERMIT FEES:
RESIDENTIAL WORK ONLY:
Fee for all residential systems combined ... $75.00
Check Type of Work Involved:
n Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
❑ Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
n Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
n Audio and Stereo Systems
n Boiler Controls
n Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
n Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
n Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
n 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