Permit u CITY OF TIGARD ELECTRICAL PERMIT
`'"!' - COMMUNITY DEVELOPMENT Permit #: ELC2011 -00088
13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/16/2011
TIGARD Parcel: 1S 136DB02601
Jurisdiction: Tigard
Site address: 11606 SW PACIFIC HWY 100
Project: Simpson Subdivision: Lot: 0
Project Description: Install (2) services and (3) branch circuits.
Contractor: GOLD CREST GENERAL CONTRACTING INC Owner: WILLIAM SIMPSON
DBA CHAMPION ELECTRIC 7094 SWASH CREEK CT
4923 NE 145TH AVE TIGARD, OR 97223
VANCOUVER, WA 98682
P
PHONE: 503 - 805 -5603
HONE: 360- 448 -3313
FAX:
FEES
Quantity Description Date Amount
1 ea Services or Feeders - 200 02/16/2011 $100.70
Specifics: amps or less
1 ea Services or Feeders - 201 to 02/16/2011 $133.56
Type of Use: COM 400 amps
Class of Work: ALT 3 crt Branch Circuits w /Purchase 02/16/2011 $22.26
Service or Feeder
Type of Const: 1 ea 12% State Surcharge - 02/16/2011 $30.78
Occupancy Grp: Electrical
Total $287.30
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 0 52- 001 -0090. You u - _ • - • es or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued Byf /'%�� •e • •ttee- 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:
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 ' d 1 A FOR OFFICE USE ONLY .
City of Tigard i "n -. Received
,2 )t 1/ � :' Permit No.: // DDdgc
A. !PI
- n 13125 SW Hall Blvd., Tigard, OR 97223- Plan Review
Phone: 503.718.2439 Fax: 503.590,9641t 1 1 2011 Date/By: Other Permit:
Inspection Line: 503.639.4175 Date Ready/By: Juris: ® See Page 2 for
TIGAR Internet: www.tigard - or.gov '..31TY OF ri y iCAM Notified/Method: Supplemental Information
TYPE OFtWt)itK'Ii1/45 UWtISION PLAN REVIEW ,
❑ New construction J1 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.
❑ 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 El Commercial /industrial ❑ Accessory building amps for all other installations. buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
❑ Emergency system. larger separately derived system.
JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "I -3 ",
Job no.: Job site address: 1 (. ( 514/ ``,, 57 J Six or or more residential Recreational parks.
• QC 1 PLC,.
G �' �/ �/ Qp ❑ Six or more residential units. ❑Rr vehicle
City/State/ZIP: / ID Health-care facilities. ❑ Supply voltage for more than
Ty (I 6t9 / 6 R ❑ Hazardous locations. 600 volts nominal.
Suite /bldg. /apt. no.: Project name: ( _ 0 Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Description I Qty. I Fee. I Total I .
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'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
sq. 75.00 2
DESCRIPTION OF WORK ( with above 9 )
ft.
Limited energy, multi - family 75.00 2
A Di) 4 - 32, w ) o Airy - EA t' 4 i R t.J b 6 Con H •C c-414 o g '.4,-tdc L residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
fDD i - 7.604- nit clry W /tv1 )AJ ®15 CO /PI 'c - /50a P4-0. L 200 amps or less 1 100.70 /OO 2
® PROPERTY OWNER ❑ TENANT 201 amps to 400 amps ( 133.56 I `33 7....-- 2
401 amps to 600 amps 200.34 2
Name: \A/10.A E4 M S I ►'t1 50 ti 601 ' 601 amps to 1,000 amps 301.04 2
Address: 701 4- c,,,,, 4#. C v - { ' K C r Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: TI 6.1et R ( O 0, 932,23 relocation
a
Phone: ( I•' j p 3) �Q i 3 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
vi. APPLICANT I ❑ CONTACT PERSON ' above service or feeder fee, 3 7.42 22 2
each branch circuit
Business name: L,b e pt , �SY. Cruklr;YA 4 L to/di-0,40 /k/e_ B. Fee for branch circuits without
service or feeder fee, first 56.18 2
Contact name: t,34 (
e ka^r 1 c01s [ry'}:L► L - jy(grr eL e-ki branch circuit �
_ Each add'( branch circuit 7.42 I
Address: kg A.10 145 1 Ade Miscellaneous (service or feeder not included) •
/State /ZIP: Each manufactured or modular
Ci
ri Co LAte1Z wig q , 2 _ dwelling, service and/or feeder 67.84 2
3 i 3
Phone: (3(RU } I Fax: : ( ) Reconnect only 67.84 2
Pump or irrigation circle 67.84 2
E -mail: C C to V 4 i e,•e tr €; (o e eB 61>•CGt S't' Yt1'e' Sign or outline lighting 67.84 2
l CONTRACTOR e _ Signal circuit(s) or limited- energy
Business name: go Lb, a a E - r 02.4 - L ,e Ot�rf Ac`r- I ,Ji:a- fj( �� panel, alteration, or extension. Paget 2
Each additional inspection over allowable in any of the above
Address: 41 2 3 i.l r (4 ...,,,�� Avf vow G v, t_rz wA -4PlQ cZ
Additional inspection (1 hr min) 66.25/ hr
-
City /State /ZIP: Investigation (1 hr min) 66.25/ hr
2 Industrial plant (1 hr min) 78 18/ hr
Phone: ( l 0) �-�- 3 - 3 1 -2 ) Fax: ) Inspections for which no fee is 90 00/ hr
��j /, specifically listed (%2 hr min)
CCB Lic.: el q (¢7 61 /06 Lic.: C r 7 ,i-,. Suprv. Lic.: G�',4 /�� .7 ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: , / f o Subtotal: � `�
Plan review (25 /o of permit fee):
Print name: 1"4A C L 4 ; v E 6,E,--t2_ i l . te: 2 - I ) - / + State surcharge (12% of permit fee): . O • 7 g
TOTAL PERMIT FEE: 0`187.
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 pennit.
I:\ Building \Permits\ELC- Permi[App doc 07/01/10 440- 4615T(11/05/COM/WEB