Permit CITY OF TIGARD ELECTRICAL PERMIT
1 11 - CO MMUNITY DEVELOPMENT Pe rmit #: ELC2011-00566
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718 2439 Date Issued: 10/12/2011
Parcel: 2S102BB00811
Jurisdiction: Tigard
Site address: 10270 SW BROOKSIDE PL
Project: HERMANSON Subdivision: BROOKSIDE PARK Lot: 5
Project Description: (1) branch circuit for house gounding.
Contractor: OWNER Owner: HERMANSON, CHRISTOPHER ALLEN
10270 SW BROOKSIDE PL
TIGARD, OR 97223
PHONE PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo /Purchase 10/12/2011 $56.18
Specifics: Service or Feeder
1 ea 12% State Surcharge - 10/12/2011 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 her 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 i .rk is suspended for more the 180
days ATTENTION Oregon law requires you to follow the rules adopted by the Oregon Utility Notification c - • ter hose rules are set forth in OAR
952- 001 -0010 through OA •52- 001 -0090. You may obtain c of the rules or direct questions to OUNC by calling 503 •87 •rr 800 332 2344,
Issued By • PermitteeSignature: q £.zi
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 . OFFICE USE ONLY
City of Tigard Date /B . �/ ) Permit No . 1
13125 SW Hall Blvd , Tigard,OR ' Plan Review
II
7 ' Phone. 503.718 2439 Fax 51,, 'i : p• ���� Date /By Other Permit
T I G A R D Inspection Line • 503 639 1 y �� Date ReadyBy ails El See Page 2 for
Internet: www.tigard -or gov � ` r Q► l Q � Notifie Supplemental Information
PE
TY OF WORN Q•V \- PLAN REVIEW
❑ New construction - dition /altera t 1 y ement
El Demolition ❑ Other: �\� Please check all that apply (submit 2 sets of plans whtems checked below)
❑ Service or feeder 400 amps or more ❑ Building over three stories
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
- and 2- family dwelling ❑ Commercial /industrial ❑ 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
�r ❑ Addition of new motor load of ❑ "A ", "E ", "l - ", "I - ",
Job no.: Job site address: ) 0 21 o S ' �12.A"OK5 I F 0 z- 4-C.t= or more occupancy
q 17 ❑ Six ix o or r moo re a residential units ❑ Recreational eational vehicle parks
'rl 04-00 6J2 1 7 7.-2- 3 O Health -care facilities ❑ Supply voltage for more than
Hazardous locations 600 volts nominal
Suite /bldg. /apt. no.: Project name: //Ek/Yl 1 l\i so ❑ Service or feeder 600 amps or more
FEE SCHEDULE
Cross street/directions to job site: Description I 0t'. 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 I
Tax map /parcel no.: Limited energy, residential 75 00 2
DESCRIPTION OF WORK (with above sq ft )
Limited energy, multi - family 75 00 2
42/ taC 7—"t/ , V�d r/ . residential (with above sq ft )
Services or feeders installation, alteration, and/or relocation
200 amps or less 100 70 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133 56 2
HER j ��` 401 amps to 600 amps 200 34 2
Name: G>l I S �7 ER yn A 601 amps to 1,000 amps 301 04 2
Address: / o 2_7o S W $12.0-6 KS) D e r Lii -Li" Over 1,000 amps or volts 552 26 2
Temporary services or feeders installation, alteration, and /or
City /State /ZIP: -i
f 4 , o 9 7i 2-3 relocation
Phone: ( ) Fax: ( ) 200 amps or less 59 36 1
201 amps to 400 amps 125 08 2
Owner installation: This 'nstallation is being made on property that I own which is not
intended for sale, lea/ , ` , • change, 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: J ,' — I
,
— Date: IC 41e2-D) f A Fee for branch circuits with
❑ APPLICA `T ❑ 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 �( ),r 2
Contact name: branch circuit
Each add'I branch circuit 7 42 2
Address: Miscellaneous (service or feeder not included)
Each manufactured or modular 67.84 2
City /State /ZIP: 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:
panel, alteration, or extension Page 2 2
Each additional inspection over allowable in any of the above
Address: Additional inspection (I hr min) 66 25/ hr
Investigation (1 hr min) 66 25/ hr
City/State/ZIP: Industrial plant (1 hr min) 78 18/ hr
Phone: ( ) Fax: ( ) Inspections for which no fee is 90 00/ hr
specifically listed (% hr min)
CCB Lie.: Electrical Lie.. Suprv. Lie.: ELECTRICAL PERMIT FEES
Subtotal ST ; l r
Suprv. Electrician signature, required: Plan review (25% of permit fee)
Print name: Date: State surcharge (12% of permit fee) - 7 1 1
TOTAL PERMIT FEE °(p , 1 ).
Authorized signature: This permit application expires if a permit is not obtained within 180
Print name: Date: * days after it has been accepted as complete.
Number of inspections allowed per permit
1 \Ruddmg\Permrts \ELC- PermitApp doc 07/01/10 440- 4615T(11/05/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:
❑ Audio and Stereo Systems*
n Burglar Alarm
n Garage Door Opener*
n Heating, Ventilation and Air Conditioning System*
n Vacuum Systems*
❑ Other:
COMMERCIAL WORK ONLY:
Fee for each commercial $75.00
system
(SEE OAR 918 309 - 0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
n Data Telecommunication Installation
n Fire Alarm Installation
❑ HVAC
n Instrumentation
❑ Intercom and Paging Systems
n Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
n Outdoor Landscape Lighting*
❑ Protective Signaling
n Other
Total number of commercial systems:
*No licenses are required. Licenses are required
for all other installations
1 \Buddmg\Permits \ELC- PermitApp doc 07/01/10
k
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing per mits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that a II subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I w ill
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
Print Name of Permit pplicant
/p.,Zrzaf I
Signature of Perm' Applicant Date
Permit #: ,. -
Address: f 7r7 ( __ e, r4t(Sir(P /t . ��M1lfit
•
Issued by: ,- I . Date WV)/
This Copy for Permit Offices