Permit CITY OF TIGARD ELECTRICAL PERMIT
•
COMMUNITY DEVELOPMENT Permit #: ELC2011 -00501
1 3125 SW Hall Blvd., Tigard OR 97223 503 718.2439 Date Issued: 09/13/2011
.TIGARD Parcel: 2S 112CA 13200
Jurisdiction: Tigard
Site address: 15508 SW 76TH AVE
Project: Holzang Subdivision: RENAISSANCE WOODS NO.2 Lot: 56
Project Description: (2) branch circuits to reconnect furnace and NC
Contractor: TRI COUNTY TEMP CONTROL INC Owner: HOLZGANG, MARY ANN
13150 S CLACKAMAS RIVER DR 15508 SW 76TH AVE
OREGON CITY, OR 97045 TIGARD, OR 97224
PHONE' 503 - 557 - 2220
PHONE' 503 - 968 -2076
FAX' 503 - 557 -0919
FEES
Quantity Description Date Amount
2 crt Branch Circuits wo /Purchase 09/13/2011 $63.60
Specifics: Service or Feeder
1 ea 12% State Surcharge - 09/13/2011 $7 63
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $71.23
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 OAR •52 -00 i.•0 Y•u may obtain a copy of the rules or direct questions to OUNC by calling 503 232 1987 or 1 800 332 2344
Issued By: 1( AlV ∎' /f Permittee 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 Applicatio li n,° .1 I
City of Tigard -Received 4 / _ c r - ' ennit No.:LLC• //— /0S'®/
I 13125 SW Hall Blvd., Tigard, OR 97223 S EP 1 2 2011 Man Review
!'hone: 503.639.4171 Fax: 503.598.1960 Date/B : Other Permit:
i I c'i A R 0 inspection Line: 503.639.4175 ``°� OF T ? Date Read See Page 2 for
Internet: www.tigard- or.gov � i 9 '� L 't s �i c %`it t!J Notified/Method. supplemental Information
ni in Milt in ri •it , rir'treno
TYPE OF WO1 K " ` PLAN REVIEW
Nemo check all that apply (submit 2 sets of plans whims checked below):
❑ New construction ® Addition /alteration/replacement
❑ Service or feeder 400 amps or more ❑ Building over three stories.
❑ Demolition ❑ Other: where the available fault current ❑ Mannas 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 ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pwnp. ❑ Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑ Emergency system larger separately derived system.
n'Ar � f,, ❑ Addition of new motor load of ❑ "A ", "E ", "I -2 ", "1 -3 ",
Job no.: I Job site address: (5 V V V � �j I OOHP or more. occupancy.
❑ Six or more residential units ❑ Recreational vehicle parks
City/State/71P j' $1122 $1122 7f' I ❑ Health -care facilities. ❑ Supply voltage for more than
► 1 ❑Hazardous locations. 600 volts nominal.
Suite/bldg. /apt. no.: I Project name: ❑ Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job sitc: Description 1 Qty. 1 Ere. 1 Total i
New residential single- or multi - family dwelling unit.
-hrefuttes attached garage.
Subdivision: Lot no.: 1,000 sq. R. or less 168.54 4
Ea, add'l 500 sq. ft. or portion 33.92 1
Tax map /parcel no.: Limited energy, residential
DESCRIPTION OF WORK (with above sq. It.) 67.84 2
/�
y W� Limited energy, multi - family 67.84 2
�(�pp
0 I COIn "1 ��Wet residential (with above sq. ft.)
1 a r c r a nd r (i dner Services or feeders installation, Alteration, end /n relocation
200 amps or less 100.70 2
PROPERTY OWNER 1 ❑ TENANT 201 amps to 400 amps 133.56 _ 2
Mark/ f tin , t i t 11 fn � 401 amps to 600 amps 200.34 2
Name: `�( U 711 Ij no (i�J ( �if L
601 amps to 1,000 amps 301.04 2
Address: ` Y ) Over 1,000 amps or volts 552.26 2
City/State /ZLP: Temporary services or feeders installation, alteration, and /or
relocation
Phone: (0) q(, -- 2fr j I Fax: ( ) 200 turps or less 59.36 1
Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 125.08 2
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 1 ❑ CONTACT PERSON above service or feeder fee,
7.42 2
each branch circuit
Business name: Same as contractor 13. Fee for branch circuits
— Contact name: Diane Mason without service or feeder fee, 56.18 2
first branch circuit
Address: Each addl branch circuit ) 7.42 2
Miscellaneous (service or feeder not included)
City/State /ZIP: Each manufactured or modular
67.84 2
dwelling, service and/or feeder
Phone: ( ) Fax: : ( ) Reconnect only 67.84 2
E -mail: Pump or irrigation circle 67.84 2
CONTRACTOR Sign or outline lighting 67.84 2
Signal panel, or limited -
Business name: Tri County Temp Control
energy p alteration, or
Address: 13150 S. Clackamas River Drive extension. Describe: ' Page 2 2
City/State /ZIP: Oregon City, OR 97045 Each additional inspection over allowable in an of the above
Per inspection 66.25
.
PCB l JlD W Phone: (503) 557.2220 Fax: (503) 557,0919 /Investigation per hour (1 hr min) 66.25
Lic.: 72623, Electrical Lic.: " 41 ,3 Suprv. Lie.: • Industrial plant per hour 78.18
ELECTRICAL PERMIT FEES
Suprv. Electrician signature, required: Subtotal:
Print nllme ' Date:
(� Plan review (25% of permit fee):
State surcharge (12% of permit fee):
Authorized signature: 4 �Y'�.y n V_ __ ' - ; TOTAL PERMIT FEE: v
` `� � This permit application expires if a permit is not obtained within 180
Print name: Diane Mason Date: �i days after It has been accepted as complete.
7 • Number of inspections allowed per permit,
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