Permit ,
14 iiii
Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: n Owner ❑ Applicant n Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
CANCEL PERMIT APPLICATION. 0 1 0
❑ REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below). 7 "
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). ��
Permit #: EL-C-3 1 ( — 0OD-Z Fr
Site Address or Parcel #: 9po aiJ / 8 /Vl t
Project Name: I t V l S ( pr-
Subdivision Name: (J C' - Lot #: '—
EXPLANATION: c S ; l J 1- v , � .i:/ L / /i Imo.
/ -------1 C-if) ,.e.t ( i___Vrr 1 r fr /Ve)-■i l S' s t ,/ki iltee- - A.)
ore) , i
c . 1 cw• Uv, L1
Signature: r _ _ • Date: / //
Print Name: (Rig - r, JobJ jr K1—
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
e) 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 S s Admin: Date B a71 Rte to Bld . Admin: Date , / // B441,7
Refund Processed: Date ,� • By ./ . Invoice Processed: Date By
Permit Canceled: Date E /�/ /, B Parcel Tag Added: Date By
Receipt # Date Me od Amount $
I:\ Building \Forms \ReqPermitAction.doc Rev 07 /26/07
Electrical Permit ApplicatioV 0,„,4 t - - ' FOR OFFICE USE ONLY .
13125 .
. ,
.,,
City q.-' \7,2 Received , A
, I at Fif
E
SW Hall Blvd., Tigard, OR;s17,2,4 t .„..'', / k 'Ian Review
° ', ' Phone: 503.718.2439 Fax: 503'!5981419611' \\ i"* r Date/B : Permit No.: *---• r
- - ..441 ' x
Other Permit: • 9 ' _
TIGARD r's
1 .411
Inspection Line: 503.639.4175 % V iv, 674 1 e Date Ready/By: Saris: _ ' Ed See Page 2 for
Internet: www.tigard-or.gov c'..-`" ,.), Notified/Method: 1 Supplemental Information
217P i ILkSliartn:0#114***:',AINOV:t,'1,
0 New construction El AdditionialteratibiqePjaPirin Please check all that apply (submit 2 sets of plans w/items checked below):
1:3 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition Miler: 6i ( where the available fault current 0 Marinas and boatyards.
i1:4"EAR, exceeds 10,000 amps at 150 volts OT 0 Floating buildings .
less to ground, or exceeds 14,000 0 Commercial-use agricultural
0 1 - and 2-family dwelling g 0 Accessory building amps for all other installations. buildings.
0 Multi-family 0 Master builder 0 Other: 0 Fire pump, El installation of 75 KVA or
illtr : 'iiii'R Alsi
'" atroW'' ' '' "' '' ' '''''' 1,1"1"'” El Emer system. larger separately derived system.
* , .!--1ag r- -; , z7c.;.AIL b ,„: , nv1.1, , '.'Z''241:41 0` 0 Addition of new motor load of 0
100HP or more occupancy.
Job no.: Job site address: Ci ( c9 sw @U_.}' rta VY'I 0 Six or more residential units. 0 Recreational vehicle parks.
City/State/ZIp.----R5aA c_.)-12..., 0 Health-care facilities. 0 Supply voltage for more than
I 0 Hazardous locations. 600 volts nominal.
Suite/bldg./apt. no.: 0 Service or feeder 600 amps or Project name7r (
i 1 \) i- t ` on , ( a l more.
jt k,_ ,,,, , , , , e , e0 , _ m _ , o ,
iwilittaf:',t fillgOt.$,P.figaiaSSej ':
Cross street/directions to job site: r-1.
Li ( U_ c- LI-Y" Yla_ yr> Description 1 OM 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'I 500 sq. ft. or portion 33.92 1
Tax map/parcel no.: Limited energy, residential
75.00 2
*$14ctiqqiiikt#0,kil' $;N:fia:,11Emegi,, with above sq. ft )
Limited energy, multi-family
75.00 2
r\th._. ) ryi is-- Lrne rd ,--_,:ny, residential (with above sq. ft.)
Services or feeders installation, alteration, and/or relocation
200 amps or less 100.70 2
Eaa40 . ata,21,7:: 201 amps to 400 amps 133.56 2
Name: p s -u
s. k. 4 .. ir I
.q-„ 401 amps to 600 amps
601 amps to 1,000 amps 200.34
301.04 2
2
Address: Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation, alteration, and/or
City/State/ZIP: relocation
Phone: (95•) Bos^... 1-1 10 Fax: ( ) 200 amps or less 59.36 I
201 amps to 400 amps 125.08 2
Owner installation: This installation is being made on property that I own which is not
401 amps to 599 amps 168.54 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701.
Branch circuits - new, alteration, or extension, per panel
Owner signature: Date: A. Fee for branch circuits with
*-00,1;961 above service or feeder fee,
742 2
MEN:! ,,,,, . , , ,,, , ,,, , ,, , ,, ,, ,, ,,,,,6:'allPke' , j - -' , each branch circuit
Business name: ,, c _,,, .
- B. Fee for branch circuits without
1 (y\A1 to , r - S I r , _
service or feeder fee, first
56.18 2
Contact name: branch circuit
■ C *to xs-C2—. Each add'I branch circuit 7.42 2
Address: [ s.,D s t....... ) 1.14 fku_o_ Miscellaneous (service or feeder not included)
Each manufactured or modular
City/State/ZIP: O■K _, 1 - 7 2 - 2 -€1
1 dwelling, service and/or feeder 67.84 2
2
Reconnect only 67.84
Phone: (51 36c4 - _ 2.2_1 I Fax: : (9)3) . 3( 2 (.4 - < 8 / s-- -
Pump or irrigation circle 67.84 2
E
,, , . o outline lighting I 67.84 Li 6 2
1,M
IlielZ::::',:lilfirker3,g0coNT*A0 .gilillirliRlblatElM:::F 121 , 1 ignal circuit(s) or limited-energy
panel, alteration, or extension. Page 2 2
Business name: )cy e S / F,-, (_-C) Each additional inspection over allowable in any of the above
Address: Additional inspection (1 hr mm) 66.25/ hr
Investigation (1 hr min) 66.25/ hr
City/State/ZIP:
Industrial plant (1 hr min) 78.18/ hr
Phone: ( ) Fax: ( ) r c , , .. Inspections for which no fee is
90.00/ hr
SCOL4 (../0" specifically listed ( hr mm)
CCB Lie.: k 0 /4-t Electrical Lic.: ',.) _ mas Suprv. Lic.: s-66 ' S1 4 IllgarIMantagt(OirkWV:;FOVRIINKV.% :; 'aq•
...--
Subtotal: (/ `i
Suprv. Electrician signature, requi -c1
0 , - . 9
, -e----- -..---z....---Z1------
Plan review (25% of permit fee):
Print nameq*-,: /pc yLc, il.0 Date: 2 ,_ 2 1 I State surcharge (12% of permit fee): S. / 4
TOTAL PERMIT FEE:
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.
IABuilding \Permits \ELC-PermitApp doe 07/01/10 440-46t 5T( I I /05/COMAVEB
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