Permit CITY OF TIGARD ELECTRICAL PERMIT
11111
COMMUNITY DEVELOPMENT Permit #: ELC2010 -00686
13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/15/2010
T i GARD Parcel: 2S110DCO2400
Jurisdiction: Tigard
Site address: 11565 SW DURHAM RD 110
Project: Dr. Tollenarr Subdivision: Lot: 0
Project Description: (6) branch circuits for TI in health -care facility.
Contractor: FITZPATRICK ELECTRIC INC Owner: MOODY 2005 TRUST
10129 N SMITH ST BY PAUL W & LINDA L MOODY TRS
PORTLAND, OR 97203 9811 NE 114TH CIR
VANCOUVER, WA 98662
PHONE: 503 - 289 -4196 PHONE:
FAX: 503 - 289 -0912
FEES
Quantity Description Date Amount
6 crt Branch Circuits wo /Purchase 12/15/2010 $93.28
Specifics: Service or Feeder
1 ea Plan Review Electricial 12/15/2010 $23.32
Type of Use: COM 1 ea 12% State Surcharge - 12/15/2010 $11.19
Class of Work: ALT Electrical
Type of Const:
Occupancy Grp:
•
Total $127.79
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 wit
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 ado. - • • the Oregon Utility Notification Center. Those rules are set forth in OAR
952- 001 -0010 throu• • ' • '7 =52- 001 -0090. You a ob - • - - - rules or direct qu - stions to OUNC by calling 503.232.1987 0 . .332.234 .
Issued By _ . Perm itteeSignature: r dc" / Tt
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 503.6394175 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 Applicatia FOR OFFICE USE ONLY
City Received
Of Tigard / Permit No.: A Xy .00
111 q 13125 SW HaII Blvd., Tigard, OR 972Z ( 14 201 Plan n
Phone: 503.718.2439 Fax: 503.598. �§ Da te B Rev : iew Z. Other Permit: �U otOlU' OD c�lP
T 1 G A R D Inspection Line: 503.639 Date Ready/By. Juris: ® See Page 2 for
Internet: www.tigard- or.gov CITY OF TIGARI Notified/Metho �j / y p Supplemental Information
TYPE O F UWO RK DIVISION /��}� W / � j • PLAN REVIEW
New construction Addition alteration /replacement
V Y" . ( Please check all that apply (submit 2 sets of plans w /items checked below):
❑ Service or feeder 400 amps or more 0 Building over three stories.
El 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 ig Commerciallindustrial ❑ 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 ",
} 100HP or more. occupancy.
Job no.: Job site address: t 1 S G S s 0 P U H f�, AA ❑ vehicle arks.
V" 1 ❑Six or more residential units. p
City /State /ZIP: S ). nA z. d -1 3... L f ❑ Health-care a Hazardous facilities. ❑ Supply 0volts voltage for more than
1 ❑ Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: % ( 1 Project name: 1 (-C_I (Z--- ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description 1 Qty. I Fee. 1 Total J
New residential single- or multi - family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4
Ea. add'I 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. ft.) 75.00 2
Limited energy, multi - family 75.00 2
lit S T. Al. L L 1 t t. TA ` G P....AD M C C, t residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
AT (t i J "'k CPt v C " D-6 t'C V . 200 amps or less I I 100.70 I 2
❑ PROPERTY OWNER ❑ 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
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: 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
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, per panel
Owner signature: Date: A. Fee for branch circuits with
❑ APPLICANT I ❑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 66A 2
Contact name: branch circuit
Each add'I branch circuit 5 7.42 3 -7 . ( 0 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: V- T panel, alteration, or extension. Page 2 2
Zp i ' -U2. �6 r7feL r N� Each additional inspection over allowable in any of the above
Address: J G t 4 `V . 5 rtn 1 /-f Additional inspection (1 hr min) 66.25/ hr
City /State /ZIP: p p v 0 it. 9 7 ,2Q Investigation (1 hr min) 66.25/ hr
Industrial plant (1 hr min) 7818/ hr
Phone: (5 'g _ c1 / ? Fax: (51v3) Q.89 - ® R'la Inspections for which no fee is 90.00/ hr
specifically listed (%] hr min)
CCB Lic.: / 7 3. 3 g Electrical Lic.:C J , S
Suprv. Lic.: 5-a (65- ELECTRICAL PERMIT FEES
/a17J 4777/79 Subtotal S
Suprv. Electrl tan signature, required:- /
aGlc. c - .�- ° � -� Plan review (25% of permit fee): 2 3 .-3 2.
Print name: 'T'pp p 6 ! ez47-,_,/C<, Date: / 9,../e) State surcharge (12% of permit fee): H.0
TOTAL PERMIT FEE: / 2.,'7 77
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.
I:l BuildinglPermits 'ELC- PermitApp.doc 07/01 /10 440-4615T(I I /05/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:
n Audio and Stereo Systems*
❑ Burglar Alarm
n Garage Door Opener*
n 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:
n Audio and Stereo Systems
n Boiler Controls
n Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
n HVAC
Fl Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
n Medical
n Nurse Calls
❑ Outdoor Landscape Lighting*
n Protective Signaling
n Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1:\Building\Permits\ELC- PermitApp.doc 07/01/10