Permit CITY OF T I GA R D ELECTRICAL PERMIT
PERMIT #: ELC2001 -00562
,II DEVELOPMENT Tigard, SERVICES 639 -4171 DATE ISSUED: 11/13/01
PARCEL: 2S 110CD -00107
SITE ADDRESS: 15905 SW 116TH AVE
SUBDIVISION: KING CITY NO. 2 ZONING:
BLOCK: LOT : JURISDICTION: KIN
Project Description: Installation of surge suppressor on circuit panel. Job No: 144308 -81672
RESIDENTIAL UNIT TEMP SRVC /FEEDERS MISCELLANEOUS
1000 SF OR LESS: 0 - 200 amp: PUMP /IRRIGATION:
EACH ADD'L 500SF: 201 - 400 amp: SIGN /OUT LINE LTG:
LIMITED ENERGY: 401 - 600 amp: SIGNAL /PANEL:
MANF HM/ SVC/ FDR: 601 +amps -1000 volts: MINOR LABEL (10):
SERVICE /FEEDER BRANCH CIRCUITS ADD'L INSPECTIONS
0 - 200 amp: W /SERVICE OR FEEDER: PER INSPECTION:
201 - 400 amp: 1st W/O SRVC OR FDR: 1 PER HOUR:
401 - 600 amp: EA ADD'L BRNCH CIRC: IN PLANT:
601 - 1000 amp: PLAN REVIEW SECTION
1000+ amp /volt: > =4 RES UNITS: > 600 VOLT NOMINAL:
Reconnect only: SVC /FDR >= 225 AMPS: CLASS AREA /SPEC OCC:
Owner: Contractor:
NORTH SHORE CORP, THE COCHRAN ELECTRIC
BY BANK OF AMERICA OREGON BROADWAY ELECTRIC
PO BOX 6400 -UNIT #2814 626 SE MAIN
PORTLAND, OR 97228 PORTLAND, OR 97214
Phone: Phone: 234 -6564
Reg #: LIC 77942
SUP 3184S
ELE 37 -546C
FEES Required Inspections
Type By Date Amount Receipt Wall Cover
PRMT CTR 11/13/01 $46.85 2720010000( Elect'I Final
5PCT CTR 11/13/01 $3.75 2720010000( EXPIRED
Total $50.60
This Permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable
laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if
work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification
Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0080. You may • ies of these rules or direct questions to
Permit Signature: Issued B
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease, or rent.
OWNER'S SIGNATURE: DATE:.
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC'N: DATE:
LICENSE NO: g`''1 7 S
Call 639 -4175 by 7:00pm for an inspection the next business day
• Electrical Permit Application
RFC I'/' - ; Date received: (0/?j! /fJ( Permit no.: ZL C,1pG / -OU5
iii City of Tigard Pro ect/a 1 no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard, Zit r243 2 of]; Date issued: By: I Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 COMMUNITY U1 VLLUMlVitt+f l Case file no.: Payment type:
Land use approval: .
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family ❑ Tenant improvement
0 New construction ❑ Addition/alteration/replacement 0 Other. 0 Partial
JOB SITE INFORMATION
Job address: 151(25 5,0 ?Block: b no.: Suite no.: Tax map /tax lot/account no.:
Lot: 'Subdivision:
Project name: Mo I R a 1.1 _..1y/Oi I Description and location of work on premises: ,),tr i ?,(,l, 0 0 - / i l jai,a)
Estimated date of completion/inspection: ri l j _ (;>_, b _
CONTRACTOR APPLICATI 0 FEE SCHEDULE
Job no: 1492p$ —g I (O - Fee Max
Description Qty. (en.) Total no. insp
Business name: C \ . 45) �130..1,,,0..k t\ ` - • New residential - single or multi per
Address: ( 5C Ma' dwellinguntlncludesattachedgarage.
City: - ? Q r - -\ \ I State: ZYR I ZIP: q - 4`2_14 Service included:
Phone6S3 23445( I Fax: 23 i-2(s) I E -mail: 1000 sq. ft. or less • 4
CCB no.: "7 zc 4-2_ Elec. bus. lic. no: 3 — 5 c{ ( Q s` Each additional 500 sq. ft. or portion thereof
Limited energy, residential 2
City /mete lic. n Limited energy, non- residential 2
�,. � G 1 (013' 0 I Each manufactured home or modular dwelling
Signature of su rvising electrician (required) Date Service and/or feeder 2
Services or feeders — installation,
Sup. elect. name (print': - li b. _ x � License no: 3 S alteration or relocation:
PROPERTY OWNER 200 amps or less 2
Name (print): 201 amps to 400 amps 2
Mailing address: 401 amps to 600 amps 2
601 amps to 1000 amps 2
City: I State: I ZIP: Over 1000 amps or volts 2
Phone: I Fax: I E -mail: Reconnect only 1
Owner installation: The installation is being made on property I own Temporary services or feeders - -
which is not intended for sale, lease, rent, or exchange according to installation, alteration, orrelocation:
ORS 447, 455, 479, 670, 701. 200 amps or less 2
201 amps to 400 amps 2
Owner's signature: Date: 401 to 600 amps 2
ENGINEER Branch circuits - new, alteration,
Name: or extension per panel:
A. Fee for branch circuits with purchase of
Address: service or feeder fee, each branch circuit 2
City: State: • ZIP: B. Fee for branch circuits without purchase
of service or feeder fee, first branch circuit: / 2
Phone: Fax: E -mail:
Each additional branch circuit:
PLAN REVIEW (Please check all that appl) Misc. (Service or feeder not included):
❑ Service over 225 amps- commercial ❑ Health -care facility Each pump or irrigation circle 2
❑ Service over 320 amps- rating of 1&2 ❑ Hazardous location Each sign or outline lighting 2
family dwellings ❑ Building over 10,000 square feet four or Signal circuit(s) or a limited energy panel,
❑ System over 600 volts nominal more residential units in one structure alteration, or extension* 2
❑ Building over three stories ❑ Feeders, 400 amps or more *Description:
❑ Occupant load over 99 persons ❑ Manufactured structures or RV park Each additional inspection over the allowable In any of the above:
❑ Egress/lighting plan ❑ Other. Per inspection I I
Submit sets of plans with any of the above. Investigation fee
The above are not applicable to temporary construction service. Other
Not all junisdict oar accept credit cards, please call jurisdiction for more information. Notice: This permit application
Permit fee $ Zt(o,&
cr
❑ Visa ❑ MasterCard expires if a permit is not obtained Plan review (at _ %) $
Credit card number: / / within 180 days after it has been State surcharge (8%) .... $ 3 ..7
Expires accepted as complete. TOTAL $ SD (DO
Name of cardholder as shown on credit card .
s EXPIRED
Cardholder signature Amount 440 -4615 (6/00/COM)
11113/2001 10:19 5036393771 CITY OF KING CITY PAGE 02!02
41 KING CITY
I5800 SW, 116th Avenue, King City, Oregon 97.24.2693
■ximaxwi Phone: (503) 639.4082 • FAX (503) 639 -3771
Notice To Contractors Working In King City
b t�
Due to an intergovernmental agreement with the City of Tigard, many building related permits
for projects in King City are issued and inspected by the City of Tigard.
If your permit application DOES NOT REQUIRE PLAN REVIEW, simply complete the
appropriate application legibly and submit it to the King City staff. The King City staff will
collect all fees and fax the application to the City of Tigard. City of Tigard staff will then create
the permit, issue the permit, and perform inspections. Please indicate on the ,permit application
whether you would like the Tigard staff to call you when the permit is ready for issuance or
whether you prefer it to be mailed without any notification. Any incomplete or illegible
application will be returned to King City staff for correction and no processing will occur until a
complete. legible application is received.
If your permit application DOES REQUIRE PLAN REVIEW, this form must be signed by a
King City staff person. King City staff will simply sign this form indicating land use approval_
Take this signed form to the City of Tigard Development Services Counter located at 13125 SW
Hall Blvd, Tigard, to submit applications and plans. Development Services Technicians are
available at 639-4171 Ext. 304 should you have any questions concerning submittal'
requirements. All permit fees will be assessed and collected at the City of Tigard.
The City of King City hereby authorizes applicant to pursue permits at the City of Tigard
Building Department for the following project:
located at: 1%105 41,,a l llt2:
II a-L
King City Representativ 1 / 3�
1 DSTS xCfY37 D9C
U � .
EXPIRED